Family Medicine Associates, INC
8853 Fox Drive, Suite 200 Thornton, CO 80260
Phone: 303-487-8817 Fax: 303-487-0429
P: 303-487-8817 F: 303-487-0429
I do authorize the release of information related to HIV/AIDS, psychological or psychiatric conditions, and treatment for alcohol and/or drug abuse.
I DO NOT authorize the release of information related to HIV/AIDS, psychological or psychiatric conditions, and treatment for alcohol and/or drug abuse.
Please choose the following option. Minimum is the last visit notes
Purpose of Disclosure. Put initials in each reason that fits
**There is a charge for a personal copy of your records.
Patient Rights: I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment, or enrollment However, I do have to signand authorization form: *To take part in a research study. * To receive health care when the purpose is to create health information for a third party. I may revoke this authorization in writing. If I do, It will not affect any actions already taken by the above named practices based upon this authorization. I may not be able revoke tothis authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are: *Fill out a revocation form (available from our office) or written communication to the office. Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.
(self/parent/legal guardian,/personal representative)