Authorization to Release Medical Information 2

1. I AUTHORIZE:

Name of sending person/organization:

Street Address:

City:

State:

Zip Code:

2. TO RELEASE TO:

Name of receiving person/organization:

Street Address:

City:

State:

Zip Code:

NAME OF CHILD OR DEPENDENT:

DATE OF BIRTH OF CHILD OR DEPENDENT:

INFORMATION TO BE RELEASED: (Check all applicable)

All Information

X-ray Reports

Immunization Records ONLY

Allergy Records

All Progress Notes

Consultant Letters

Lab Reports

Other

SPECIAL AUTHORIZATION: Check applicable box(es) and sign immediately below. By signing below, I am authorizing the office to release any and all information regarding:

Alcohol

Drugs

Mental Health

Sexually Transmitted Diseases

HIV

AIDS

Note: If this release pertains to alcohol, drug, or mental health information, please note that this information has been disclosed to you from records protected by federal confidentiality rules (42 CFR part 2). The federal rules prohibit you from making any further disclosure of this information unless additional further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

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.

Patient (if Over 18 years old) or Parent/Guardian Signature

Date:

RECORDS FROM THE TIME PERIOD:

through

PURPOSE OF DISCLOSURE: (Check applicable purpose)

Transfer of Medical Care

Personal

N/A

For Other Medical Provider

Others

I understand that this authorization shall be valid for one year. I understand that I may revoke this consent at any time except to the extent that action has already been taken.

I understand that a reasonable fee may be charged for duplication of records. An estimate of those charges will be provided upon request prior to duplication.

The requestor may be provided with a copy of this authorization

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.

Patient’s Signature (if over 18 years old):

Date:

Parent or Guardian’s Signature:

Date:

Date of Birth:

Home Phone:

Work Phone:

Your information will be encrypted.