I consent to release of information relating to psychiatric or psychological testing or treatment, alcohol, and/or drug abuse diagnosis, prognosis and treatment, and/or HIV (AIDS) testing and/or results, genetic testing/results, sickle cell anemia testing/results.
***NOTE: If this section is not completed, then records of this type, if they exist for this patient, will not be released.
AUTHORIZATION: I hereby give the releasing facility permission to disclose my individually identifiable health information as listed above. I understand that once this information is disclosed, it may no longer be protected. I understand that this authorization is voluntary, that further treatment cannot be conditioned upon my signing this authorization. I acknowledge that incomplete forms cannot be processed and that there may be a cost to copy these records.
I understand that this consent expires one year from the date of my signature unless otherwise specified below*. I understand that I can take back permission to release my medical records at any time, except to the extent that action has already been taken to comply with it. I understand that I must provide notice in writing if I choose to revoke this authorization before the date/event of expiration, and that the written revocation must be signed and dated with a date that is later than the date on this authorization. A copy, fax, or scan of this form is to be considered as valid as the original. Please retain a copy of your records for your personal use.
PLEASE ALLOW 10 DAYS FOR YOUR RECORDS REQUEST TO BE PROCESSED