Sansum Clinic
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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

Consent 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 a "Consent for Proxy Access to MyChart" and "Protected Health Information" form.
*Responsible adult is at least 18 years of ago or an emancipated minor.

Download: Consent for Proxy Access to MyChart*

*NOTE: This form must be completed and delivered to our Release of Information (ROI) department located at:

Health Information Services (HIS)
c/o Release of Information Department
Sansum Clinic
89 S. Patterson Ave.
Santa Barbara, CA 93111
(805) 692-6435 (phone)
(805) 692-4699 (fax)

Important information for patients visitng the new ROI department locationat Patterson:
1. Please call to make an appointment, especially when requesting Notary Public assistance.
2. Park in designated ROI parking space near the building entrance.
3. Announce your arrival by using the intercom located by the doorway.
4. All visitors must be accompanied by an HIS staff member into and out of the building.
5. A visitor badge must be worn and visible at all times while inside the premises.

If you are unable to register in person, please call (805) 692-6435 for further instructions.

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 (English)
Download: Consent to Disclose Protected Health Information to a Designated Patient Representative (Espanol)

Release of Radiologic Records

This form is used to request copies of CT scans, mammograms, MRIs, PETs, X-Rays and other radiologic records. The completed authorization form should be sent to:

Health Information Services (HIS)
c/o Release of Information Department
89 S. Patterson Ave.
Santa Barbara, CA 93111

Download: Authorization to Release Radiologic Records

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 Sansum Clinic: Authorization for Use/Disclosure of Protected Health Information (English)
Download Cancer Center: Authorization for Use/Disclosure of Protected Health Information (English)
Download: Authorization for Use/Disclosure of Protected Health Information (Espanol)

Outside Medical Records

Please send outside records, along with this form to:
Sansum Clinic Health Information Services
c/o Relese of Information Department
89 S. Patterson Ave.
Santa Barbara, CA 93111

Download: Outside Medical Records Form

Questions? Please contact Health Information Services at: (805) 692-4604 or outsiderecords@sansumclinic.org and a representative will be glad to assist you. This form is for medical records recieved from a non-Sansum Clinic provider or from a new patient and determinded to be part of Sansum Clinic Health Information Services/Medical Records files.

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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