MEDICAL RELEASE FORM

Patient Name

Date of Birth

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form.

In accordance with applicable law, I understand that:

This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV*RELATED INFORMATION only if I place my initials on the appropriate line below, In the event the health information described below includes any of these types of information, and I initial the line on the box below, I specifically authorize release of such information to the person(s) indicated below.

If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health health treatment information, the recipient may be prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law.

I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

Unless otherwise protected by law, information, disclosed under this authorization might be redisclosed by the recipient and this redisclosure may no longer be protected by federal or state law.

Name and address of health provider or entity to release this information:

Name and address of person(s) or category of person to whom this information will be sent:

Specific information to be released:

Entire Medical Record

From (Insert date)

To (Insert date)

Specific Portions of the Medical Record as follows:

Other:

Include: (Indicate by Initialing)

Alcohol/Drug Treatment

Mental Health Information

HIV-Related Information

Reason for release of information:

At request of individual

Other:

Date or event on which this authorization will expire:

If not the patient, name of person signing form:

Authority to sign on behalf of patient:

All items on this form have been completed and my question about this form have been answered, In addition, I have been provided a copy of the form.

Signature of patient or representative authorized by law.

Date

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