Authorization For Release Of Medical Information

Dates of Service:

This information is to be released TO:

• I understand that my complete medical record will include any office notes, lab tests and/or pathology reports and x-ray reports. I understand that there may be medically sensitive information in my medical record that may include information relating to sexually transmitted diseases, AIDS (Acquired Immunodeficiency Syndrome), or infection with HIV (Human Immunodeficiency Virus). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.
• I understand that any disclosure of information carries with it the potential for redisclosure and that the information then may not be protected by federal confidentiality rules.
• I understand that I have the right to revoke this authorization at any time. I understand that my revocation must be in writing, and I understand that the revocation will not apply to information already released based on this authorization.
• I understand that authorizing disclosure of this health information is voluntary. I can refuse to sign this authorization. However, if this authorization is needed for participation in a research study, my enrollment in the research may been denied.
• I understand that I may inspect or obtain a copy of the information to be used or disclosed.
• Unless otherwise revoked or specified, this authorization will expire twelve (12) months from the date listed below.

I have read and understood this authorization. I hereby authorize the release of the above-requested medical information.

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