Patient Health Information Release Forms

In order for your doctor to release your health information to Dr. Hirschinger, you need to complete the form below. Please note these are “fillable” forms, which means you can use your keyboard and mouse to complete the forms, and then print, and sign them, or you can print them and complete them with a pen. Please fax the completed form to 310.935.3152

Release to: Please click to download the form to have your doctor release your health information to Dr. Hirschinger.

In order for Dr. Hirschinger to release your health information to you and/or your doctor(s), you need to complete the form below. Please note these are “fillable” forms, which means you can use your keyboard and mouse to complete the forms, and then print, and sign them, or you can print them and complete them with a pen.

Release from: Please click to download the form to have Dr. Hirschinger release your health information from him to you and/or your doctor. Please fax the completed form to 310.935.3152