I, (patient name)*, with a date of birth, (patient's DOB)*, give my permission for(doctor's or hospital name who has records) * to give my medical records (as described on p. 2) to Dr. Daniel Farkas so that he can better understand my condition and help me.
By putting my initials by each item below, I understand that I give permission for records to be sent that may contain information about:
Initials* my mental health
Initials* transmittable disease I may have like HIV/AIDs,
Initials* genetic records, and/or
Initials* drugs and alcohol records.
Relationship of Authorized Representative