RIVERSIDE COUNTY MEDICAL ASSOCIATION
3993 Jurupa Avenue ¿ Riverside, CA
92506 ¿ (951) 686-3342
PATIENT EXPERIENCE RECORD
The Riverside County Medical Association is a non-profit organization of physicians and surgeons, dedicated to maintaining quality medical care and improving patient relationships. RCMA has a variety of committees volunteering their time toward these goals.
It is necessary that you personally discuss the issue with your physician before RCMA can assist in resolving any dispute. This procedure generally resolves most problems.
If the treating physician is not an RCMA member or if this matter concerns a hospital or clinic, we are unable to be of service to you. In all cases, the opinion of the Committee is advisory only. THE COMMITTEE HAS NO AUTHORITY TO REVOKE A MEDICAL LICENSE, TO SET FEES, OR TO DISCIPLINE MEMBER PHYSICIANS. RCMA HAS NO POWER TO REQUIRE YOU OR YOUR PHYSICIAN TO ACCEPT ITS ADVICE. The Medical Board of California is the only authority in the state that may take disciplinary action against the license of the physician to whom your complaint relates. The toll-free number of the Medical Board is 800-633-2322, and the Medical Board is located at 1426 Howe Ave., Ste. 54, Sacramento, CA 95825-3236. By completing and signing this form below, you agree to voluntarily participate in this review. You will be advised when the Committee has rendered an opinion. Completion of review normally takes 8 - 1 0 weeks.
YOUR NAME: PHYSICIAN NAME: (Please Print) (Please Print)
ADDRESS: ADDRESS: (City) (State) (ZIP) (City) (State) (ZIP)
TELEPHONE: TELEPHONE: (Home) (Work)
DATE OF TREATMENT:
__________________________
DATE YOU CONTACTED DOCTOR ABOUT DISPUTE:
Briefly
state the problem: (Use additional page if necessary. Attach copies of bills
and other pertinent documents. Send no originals. Use black ink or typewriter
only). PLEASE STATE EXACTLY WHAT YOUR REALISTIC EXPECTATIONS OF THE COMMITTEE
ARE.
(The Authorization for Disclosure to and Use of
Protected Health Information
below must be completed, signed and returned with the
above information)
As required by California law and the Health Information Portability and Accountability Act of 1996 (HIPAA), your physician may not use or disclose your individually identifiable health information without your authorization except as provided by California law and, if applicable, in the physician practice's Notice of Privacy Practices. Your completion of this form means that you are giving permission for the uses and disclosure described below. Please review and complete this form carefully. It may be invalid if not fully completed.
I hereby authorize the medical practice identified on the accompanying complaint to use and disclose health information concerning
_________________________________________________________________________________
(patient's name and address) as follows:
Health information to be used or disclosed (check only one box):
ٱ Any and all health information other than psychotherapy notes may be released, including, but not limited to, mental health records protected by the Lanterman-Petris-Short Act, drug and/or alcohol abuse records and/or HIV test results, if any, except as specifically provided below:
ٱ All psychotherapy notes
may be released, except as specifically provided below:
This health information may be disclosed to Riverside County Medical Association
The information may be used only to investigate and attempt to resolve the accompanying complaint.
I understand that I may revoke this authorization at any time notifying this medical practice in writing. My revocation will not affect actions taken by this medical practice prior to its receipt.
I understand that although federal law does not protect health information which is disclosed to someone other than another health care provider, health plan or health care clearinghouse, under California law all recipients of health care information are prohibited from re-disclosing it except as specifically required or permitted by law.
Effect of Refusal to Sign Authorization. I understand that my health care treatment or benefits will not be affected whether I sign or do not sign this form.
This authorization is effective now and will remain in effect until the Medical Association has finished handling this grievance.
I understand that I have the right to receive a copy of this authorization.
Signed: Dated:
Print Name: _________
If not signed by the patient, please indicate relationship:
ٱ parent or guardian of minor patient (to the extent minor could not have consented to the care)
ٱ guardian or conservator of an incompetent patient
ٱ beneficiary or personal representative of deceased patient