Below are authorizations that you might find helpful in situations where you need to request records, authorize your child to be seen, or authorize an individual to speak with us on your behalf. The forms are HIPAA compliant and will remain in effect until the date of your choice.

If you have questions about any of the authorizations, please reach out to our office (see Contact Us) and we will do our best to help out.

Authorization for Release of Medical Information - Individual


Authorization to Release Medical Information - Office/Facility


Authorization to Treat Patient without Parent or Guardian




(818) 981-9880 (Office local)


(818) 650-2894


Sherman Oaks Family Medicine, Inc.
4835 Van Nuys Boulevard, Suite 208
Sherman Oaks, CA 91403
Phone: 530-457-6465
Fax: 818-650-2894

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