FMA records release to US

Family Medicine Associates, INC

8853 Fox Drive, Suite 200 Thornton, CO 80260

Phone: 303-487-8817 Fax: 303-487-0429

Doctor/Hospital*

Address

Phone*

Fax*

P: 303-487-8817 F: 303-487-0429

Patient Name*

Date of Birth*

Date

Address

Phone*

I do authorize the release of information related to HIV/AIDS, psychological or psychiatric conditions, and treatment for alcohol and/or drug abuse.

INITIALS

I DO NOT authorize the release of information related to HIV/AIDS, psychological or psychiatric conditions, and treatment for alcohol and/or drug abuse.

INITIALS

Please choose the following option. Minimum is the last visit notes

2 years. Medical records (NO CD'S PLEASE)*

Other

Purpose of Disclosure. Put initials in each reason that fits

Referral to Specialists

Permanent Transfer

Insurance

Workers Comp

Legal Investigation

Disability Determination

OTHER

Personal

**There is a charge for a personal copy of your records.

This Authorization is valid for 1 year from the date of signature unless otherwise indicated*

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.

Signature

Date*

Date

Printed Name*

Relationship*

(self/parent/legal guardian,/personal representative)