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Consents and Authorization Forms

There are circumstances when a patient may want someone else to be able to obtain or provide medical or financial information on their behalf.

In keeping with HIPAA (Health Insurance Portability and Accountability Act) privacy and security requirements, special consents and authorizations are available at Registration for your convenience or you may download them below and bring the completed forms with you when you arrive for your appointment.

Here are some situations that may apply to you.

Treatment for a Minor

Parent(s) who are unable to bring their child(ren) in for their medical care and who have asked a responsible adult to do so, must provide written authorization for this to occur. For patient convenience, Sansum Clinic provides an “Authorization for Agent to Consent to Medical Treatment of a Minor”.
Note: Parent or legal guardian must be present for all child immunizations.

Download: Authorization for Agent to Consent to Medical Treatment of a Minor

Registration for Proxy Access to MyChart and Protected Health Information*

Patients who have someone assisting them with their healthcare and who have asked a responsible adult to have access to their personal health record through MyChart must provide written authorization for this to occur. For patient convenience, Sansum Clinic provides an “Registration for Proxy Access to MyChart and Protected Health Information” form.

Download: Registration for Proxy Access to MyChart*

*NOTE: This form must be completed and presented in-person to our Release of Information (ROI) window located at:

Health Information Services (HIS)
Sansum Clinic
317 W. Pueblo Street, Lower Level
Santa Barbara, CA
(805) 898-3188

Release of Clinical Information

Adults may have a family member, loved one or caregiver who makes their appointments or calls for medical concerns on their behalf. These representatives must be identified by the patient and documented in the patient records so our medical and support staff can provide medical information to them. For patient convenience, Sansum Clinic provides “Consent to Disclose Protected Health Information to a Designated Patient Representative” form.

Download: Consent to Disclose Protected Health Information to a Designated Patient  Representative

Release of Billing Information

Patients may have someone assisting them with their financial matters. These representatives must be identified by the patient and documented in the patient records so our medical and support staff can provide billing information to them. The completion of the “Patient Consent for Release of Billing Information” form will permit our Billing Staff to speak directly with the person regarding your financial matters with Sansum Clinic.

Download: Patient Consent for Release of Billing Information

Medical Release Forms

This form, which is also available in Spanish, is necessary for the inspection or copying of a patient’s medical records. Release of patient medical information requires completing a “Authorization for Use/Disclosure of Protected Health Information” form. There is no charge for forwarding health information to other providers including those outside Sansum Clinic.

Download: Authorization for Use/Disclosure of Protected Health Information (English)
Download: Authorization for Use/Disclosure of Protected Health Information (Espanol)

Medication Cards

Sansum Clinic provides a convenient wallet size medication card to record your medications. Bring this card with you to all appointments. In the case of an emergency or change to your medication, this card provides information on what medications you are currently taking. Presenting this card at the time of refilling any prescriptions or visiting at a new pharmacy will provide the Pharmacist with vital information to help prevent any drug interactions.

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