RELEASE OF MEDICAL RECORDS FROM OUR CLINIC TO ANOTHER

Patient Name *
Account Number *
I, the undersigned, authorize you to furnish a copy of the following medical records *
*
My DiagnosisHospital Admission SummaryOperave report’s, findings & complicaonsER TreatmentHospital NotesDr.’s NotesMy PrognosisHospital Discharge Summary
Other
I authorize the release to
Name *
Phone # *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
For the following purpose and that purpose only, any other use is forbidden: *
This authorization specifically authorizes Dr. *
to disclose records of alcohol and substance abuse.
This authorization specifically authorizes Dr. *
to disclose HIV test results or diagnosis of AIDS and AIDS related conditions.
I also understand that I may revoke this authorization at any me, except to the extent that Dr. Has already taken action in reliance on it(e.g. probation, parole, etc.), and that in any event this authorization expires automatically as described below.If *
Signature of Patient or Authorize *
Relationship to Patient *
Legal Representative *
Date *
Witness Signature *
Date *