AUTHORIZATION FOR RELEASE/REQUEST OF INFORMATION

Patient Name:

Date of Birth

WHO HAS INFORMATION YOU WOULD LIKE RELEASED?

Name:

Address:

City:

State:

Zip:

TO WHOM SHOULD THE INFORMATION BE SENT?

Name:

Fax:

Address:

City:

State:

Zip:

This information is being released at the request of the individual for the following purpose:

Continuation of Care

Litigation/Legal

Other

Transfer of Care

If Other, please specify:

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, child abuse, and treatment for alcohol and drug abuse. I understand that I have a right to stop this authorization at any time. I understand that if I stop this authorization, I must do so in writing. I understand that stopping this authorization will not apply to information that has already been released or disclosed.

Unless otherwise revoked, this authorization will expire in one year.

I understand that authorizing the release of this health information is voluntary. I can refuse to sign this authorization. I understand that I may inspect or copy the information to be used or disclosed. I understand that any disclosure of information carries with it the potential for re‐disclosure and the information may not be protected by federal privacy rules.

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

Signature of the Parent/Guardian/Patient:

Date Signed:

Relationship to Patient:

Your information will be encrypted.