Steep Falls Family Practice

P. O. Box 39 Steep Falls, Maine 04085

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Authorization to Release Protected Health Information

This authorization is for use for disclosure of protected health information pertaining to:

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Last name

Address: Street

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State

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Date of Birth

Phone Number

I hereby authorize the following health care provider:

First Name

Last Name

MD or DO

Street

City

State

Zip

Phone

Fax #

if known

To release my Protected health information to:

Steep Falls Family Practice
P. O. Box 39
Steep Falls, Maine 04085

Protected Health Information to be released:

Medical records

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Specific dates or notes

Your specific consent is required to disclose information regarding the following:

Treatment by a mental health professional or program

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Alcohol or substance use counseling

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HIV test result or status

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(Maine law requires my practice to inform you that, if this information is misused, disclosing your HIV infection status may have consequences, such as negative treatment in your personal life or by insurance companies. However, this information can also be essential in providing you with needed services and healthcare.)

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