Authorization for Use or Disclosure of Medical Information




For our patients convience the District's 'Authorization for Use or Disclosure of Medical Information' form is available for printing out and completion. It can then be faxed back to the District at the fax number on page two of the form.



Authorization for Use or Disclosure of Medical Information form

Contact Us

John C. Fremont


Healthcare District


Attn:


Matthew Matthiessen, CEO


P.O. Box 216


Mariposa, CA 95338-0216


209-966-3631   ext. 5101


209-966-3776   Fax


Send us an Email