AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

Patient's Name:

Date of Birth:

Social Security Number:

I authorize:

Name of Previous Physician:

Address:

Phone #:

Fax #:

To release my records to: Palmetto Internal Medicine & Primary Care, P.A. 300 West Butler Road Mauldin, SC 29662

The following information is to be released:

Only Last Three Office Notes/most recent lab work

All medical records including any records protected under State and Federal Confidentiality Statuses: Drug/Alcohol Treatment, HIV-related information, Psychiatric Treatment, Transfer Care and Patient Care.

Only specific portions of the medical record. Itemize portions of record to be released and indicate specific records that may not be released.

This authorization is valid for 90 days from the date of signature. I understand that revocation may not be made if the action has already been taken in reliance on this authorization.

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

Patient’s Signature

Date:

Witness

If patient is unable to sign, complete the following: Patient is a minor, (input years below) years of age

or patient is unable to sign because

Your information will be encrypted.