AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION

Patient Name: __________________

Address: ______________________
_____________________________
Date of Birth: _______________

Medical Record #_______________

Social Security #: _______________

I ____________________________________________ (name and address) hereby authorize

______________________________________________ (name and address of provider) to
disclose certain specific health information from the records of the above-named Patient to
the following individual or organization _____________________________________ (name
and address of recipient) for the following purposes:
________________________________________________________________________
_________________________________________________________________________
The specific information type and amount to be used or disclosed is as follows:
___________________________________________________________________________
_________________________________________________________________________.
I understand that the information to be released or disclosed may include information relating
to sexually transmitted disease, acquired immunodeficiency syndromes (AIDS) or human
immunodeficiency virus (HIV). It may also include information about behavioral or mental
health services and treatment for alcohol and drug abuse.
I understand I may revoke this authorization at any time by giving in writing. I further
understand the revocation will not apply to information that has already been released in
response to this authorization.
I also understand that unless otherwise revoked, this authorization will expire
following date, event or condition: ________________________________. If I
specify an expiration date, event or condition, this authorization will expire in 90
further understand that any action taken in pursuance of this authorization prior
expiration date is legal and binding.

on the
fail to
days. I
to this

I understand why I have been asked to disclose the patients health information and I am
aware of the risks and benefits of consenting or refusing to consent to the disclosure of
patients health information. I hereby release the provider, its employees, officers, and
physicians from any legal responsibility or liability arising from disclosure of the above
information to the extent indicated and authorized herein.
I understand that my authorization to disclose the health information hereunder is voluntary
and I can refuse to sign this authorization. I need not sign this authorization form in order to
receive any treatment. I understand that, once information is disclosed pursuant to this
authorization, it is possible that it will no longer be protected by medical privacy laws and
could be re-disclosed by the person or agency that receives it. However, if this information is
protected by the Federal Substance Abuse Confidentiality Regulations, the recipient may not
re-disclose such information without my further written authorization unless otherwise
provided for by state or federal law.

By signing, I acknowledge I have been provided a copy of this signed authorization

______________________________________ Dated: ______________
Patient/ guardian