Authorization and Release of Medical Records

* Release Records from : I hereby Authorize the below listed practice and its physicians, employees and agents to release or disclose to the below-named recipients all of my medical records such as those relating to psychological or psychiatric impairments, drug abuse, alcoholism, sickle cell anemia, sexually transmitted diseases, or HIV/AIDS infection.

* From Practice Name:

* Practice Phone:

Practice Fax:

Release medical information pertaining to:

* Patient Information

* Patient Name:

* Last Four Digits of SSN:

* Date of Birth:

* Release of medical records to:

* I hereby authorize the release of medical records to (Physician):

* For the purpose of:

* This authorization will expire on (date or event may not exceed one year) :

* This request and authorization apply to (choose one):

All Medical Records

Specific Medical Records

* Note: If not releasing all records, list specific records below (e.g. labs, imaging, reports, other):

If you DO NOT want certain portions of your medical records released, please check the box for the information you do not want released .

Substance Abuse

Psychological or psychiatric treatment

HIV / AIDS / STD

I understand I have the right to revoke this authorization by written notification to the privacy officer, except to the extent it has acted in reliance thereon before notice of revocation. I understand that any disclosure of information carries with the potential for an unauthorized re-disclosure which may not be protected by federal confidentiality rules. I understand that I may request a copy of this authorization. I understand that I can refuse to sign this authorization and the above-named office may not condition treatment on my signing of this authorization.

* Signature of Patient or Authorized Representative:

* Relationship to patient:

* Date Signed: