This authorization allows the healthcare provider(s) named below to release confidential medical information and
records. Note: Information and records regarding treatment of minors, HIV, psychiatric/mental health conditions,
or alcohol/substance abuse have special rules that require specific authorization.
I hereby authorize:
To release information regarding my medical history, illness or injury, consultation, prescriptions, treatment,
diagnosis or prognosis, including x-rays, correspondence and/or medical records by means of mail, fax or other
The medical information/records will be used for the following purpose: __________________________
This authorization is:
[ ] Unlimited (all records, excluding Substance Abuse, Mental Health, HIV Diagnosis/Treatment)
[ ] Limited to the following medical information: ____________________________________________
I also consent to the specific release of the following records:
Tests for Antibodies to HIV
DURATION This authorization shall be effective immediately and remain in effect until _____________
Permissions for further use or disclosure of this medical information is not granted unless another authorization is
obtained from me or unless such disclosure is specifically required or permitted by law.
A photocopy of facsimile of this authorization shall be considered as effective and valid as the original.
I have been advised of my right to receive a copy of this authorization.
Signature of Patient
Relationship if other then patient
Patient’s Name (PRINT)
Patient’s Social Security Number
Patient’s Date of Birth