Authorization to Release Medical Information

Please correct the errors described below.

to release the following information for

The information specified below may be release to:

you to include information pertaining to the diagnosis and/or treatment of HIV testing, AIDS, psychiatric illness, and alcohol and/or chemical abuse and dependency if any

I understand there is a $25 fee, per child for medical records. I also understand fees for copies are due and payable before copies are released. text

I understand this authorization expires 180 days from the date signed

I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.

I understand that photocopy or facsimile of this authorization is as valid as the original.

I understand that I may revoke this authorization at any time by notifying this office in writing and that such revocation will be not have any actions taken by this office before this revocation.

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