Authority to Release Information

Last Name:

First Name:

Middle Initial:

Street address:

City:

State:

Zip:

Phone:

Date of Birth:

SS#:

I authorize (kindly indicate name of doctor(s) below) to release medical information from my medical records and sent it to:

Name of previous doctor(s)

Name of New Physician:

Street Address:

City:

State:

Zip:

I authorize you to release my entire record to the physician named above subject to the following limitations:

No limitations

Only information related to the following:

Choose:

HIV/AIDS

Mental Health

Substance Abuse

Other

If selected, kindly provide details below:

Kindly provide details:

Any medical records from other physician or providers

This authorization will automatically expire one year from the date signed. I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance thereon.

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signed:

Date:

Printed Name:

Relationship to Patient:

Your information will be encrypted.