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Release of Records

For us to best serve you please fill out the form below to authorize your information to be send to the requested person(s).

(The execution of this form does not authorize the release of information other than that specifically described below)

Patient Name: *

DOB: *

SS#: *

Release to: *

I request and authorize the above-named doctor of health care provider to release the information specified below to the organization, agency or individual named on this request. I understand that the information to be released includes information regarding the following conditions):

Drug Abuse, if any
Alcoholism or alcohol abuse, if any

Sickle Cell Anemia, if any
Psychological or psychiatric condiitons, if any


Information requested




Dates Covered




Purpose(s) or need for which information is to be used:


Authorization

I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this Authorization at any time, except to the extent that action has already been taken to comply with it. Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in any event: on (date supplied by patient); or if revoked, in writing by patient; or 180 days from the date hereof; or under the following conditions:

Other conditions:
A copy of this Authorization or my signature thereon may, may not be used with the same effectiveness as an original.