Information to be released from: Name of Organization or Provider
Information to be sent to:
Information to be released: (please check one)
Purpose for which information is being used: (please check one)
I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.
Please initial the following to have the information excluded from the records:
I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment, or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization, please read the Privacy Notice to patients at the facility where your information is being released. I understand that once the health information I have authorized to be disclosed reaches the recipient, that person or organization may re-disclose it, at which time it may no longer be protected under Privacy Laws. This authorization will EXPIRE 90 days from date signed.
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.
*There is a .50 per page charge to release records for personal use.*
Your information will be encrypted.