Release of medical information authorization

Release of Information Authorization
Amanda E. Williams, M.D.

5555 Glenridge Connector, Suite 200

Atlanta, GA 30342

Phone 470-575-4321

Fax 459-281-0986
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
I, the undersigned, hereby authorize Amanda E. Williams, M.D. Inc. to :
Please fill in the OTHER clinican or facility's information below - not Dr. Williams' office, and not your own information.
I, the undersigned, hereby authorize Amanda E. Williams, M.D., Inc. to:
WITH THIS OTHER CLINICIAN or FACILITY (Do NOT enter your own name or Dr. Williams' name here)
This is the full name of the OTHER clinician, hospital or office that will be receiving or sending your records - NOT Dr. Williams and NOT you.
Address of the OTHER clinician or facility

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of OTHER clinician or facility
Please enter a valid phone number.Format: (000) 000-0000.
Please include at least one of the following:
Fax Number of OTHER clinician or facility
Please enter a valid phone number.Format: (000) 000-0000.
Email of OTHER clinician or facility
example@example.com
Purpose and need for such disclosure:
Information to be Disclosed (check all areas for which consent is given)
Other specified information
I understand this Authorization for Release of Information is valid indefinitely, but may be revoked by me at any time, unless it has already been relied upon. I understand that the medical records may contain information pertaining to: Human Immunodeficiency Virus (HIV) test results, Acquired Immune Deficiency Syndrome (AIDS), Drugs/Alcohol Abuse, Psychiatric and Psychological treatment. I consent to teh release of any such information contained in the records designated above. Information disclosed pursuant to this authoriation may be redisclosed by the recipient and no longer protected by federal privacy regulations.
Signature
Date signed

MonthDayYear
Date
Should be Empty:

Release of Information Authorization

Amanda E. Williams, M.D.

5555 Glenridge Connector, Suite 200

Atlanta, GA 30342

Phone 470-575-4321

Fax 459-281-0986