General Medical Records Release and Authorization for Use or Disclosure of Protected Health Information

Date

Please complete the following information:

Add patient

hereby authorize

to disclose/release the following information* to

Phone #

Fax #

Please check all applicable:

All records

Laboratory/pathology records

X-ray/radiology records

Billing records

Abstract/Summary

Pharmacy/prescription records

Other (describe specifically)

If others, describe here.

*Note: If these records contain any information from previous providers or information about HIV/AIDS status, cancer diagnosis, drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this 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.

Signature of Parent/Guardian

Date

Your information will be encrypted.