RELEASE OF MEDICAL INFORMATION

I, __________________________________, hereby authorize ___________________________________
(patient)
______________________________________________________________________________________
(address)
to release copies of medical records and other information concerning my diagnosis and treatment, including but not limited to information concerning treatment of drug or alcohol abuse, alcoholism, drug related conditions, HIV testing or treatment of HIV related conditions, psychiatric/psychological conditions. Review of records is also authorized.

The following information may be released or reviewed:

  • ( ) Case Summary                                                      ( ) Lab Work
  • ( ) Doctors Orders and Progress Notes                     ( ) X-ray Reports & Other Testing
  • ( ) Immunization Records                                         ( ) Chart problem list
  • ( ) History and Physical Exam                                  ( ) Consultations
  • ( ) Other _______________________________________________________

The above information is to be released to:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Purpose For Disclosure: ____________________________________________________________

REDISCLOSURE IS PROHIBITED WITHOUT SPECIFIC CONSENT OF THE PERSON TO WHOM IT PERTAINS.

This statement must be signed and dated and may be revoked at any time to the extent action has been taken prior to revocation. This consent will expire sixty (60) days after the date below, or sooner by choice, in which case this consent will expire on _______________________________.

_____________________________________     ________________________________________
Patient’s Name                                                                  Signature of Patient
______________________________________     _______________________________________
Address                                                                              Other person legally authorized to give consent
______________________________________     _______________________________________
Birth Date                                                                           Relationship to patient and reason
______________________________________     _______________________________________
Witness                                                                              Today’s Date

This information is being disclosed to the above individual/organization for the above stated purpose from records whose confidentiality may be protected by Federal Law.

Revised 4/99
Form #604

 

 

 

 

 

 

The form is intended to be a single page.
Nothing below here needs to be attached to your release.

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Revised November 16, 2008