Medical Record Release Authorization

Patient's Name

Account #

Birthdate

Soc. Sec. #

Explaination to Patient: This authorization for Steven Machtinger, MD to receive or release information is being requested of you to comply with the terms of the CONFIDENTIALITY OF MEDICAL INFORMATION ACT, Section 56 et seq. of the CALIFORNIA PENAL CODE.

AUTHORIZATION: I hereby authorize and request that:

STEVEN MACHTINGER, MD

100 South Ellsworth Ave. Suite 707 San Mateo, Ca. 94401

furnish information to a designee or representative of

Name

Address

City

State

Zip

This information is required for

Type of information required (including dates of treatment)

Information not to be release, if any:

This authorization becomes effective immediately and shall remain

I may revoke this authorization at any time, in writing, except to the extent that action has been taken in reliance hereon.

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.

Signature

Date

If not patient, relationship

Spouse

Parent

Guardian

Other

Your information will be encrypted.