brucejsachsmd.com - Authorization to Release Medical Records

AUTHORIZATION TO RELEASE MEDICAL RECORDS

I hereby authorize:

	NAME:	FAX:	PHONE:
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to disclose records obtained in the course of my evaluation and/or treatment to:

Bruce J. Sachs, M.D.

A Professional Corporation

501 N. El Camino Real, Suite 100

Encinitas, CA 92024

PHONE: 760-944-6520 FAX: 760-944-6525

I understand that I have the right to limit the type of information release. If I choose to limit the information released, I understand that it may be necessary for Type a label to inform the requester that
portions of the record have been withheld.

Unless otherwise indicated below, my signature authorizes the release of all medical records without exception, including any information concerning AIDS or HIV testing, psychological or psychiatric treatment, and/or alcohol or drug abuses.

This consent is subject to written revocation by the undersigned at any time except to the extent that action has been taken, and if not earlier revoked, this consent shall become invalid one year from the date of signature.

I hereby release all parties from any/all legal liability that may arise from the release of this information to the party named above.
PATIENT’S NAME:
Date:

MonthDayYear
Date
Primary Phone:
Please enter a valid phone number.
Date of Birth:

MonthDayYear
Date
SIGNED: (Signature of Patient/Spouse/Parent/Guardian/Conservator/Legal Representative)

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If signed by other than patient, indicate relationship:
IMPORTANT: Information released in accordance with this request is prohibited from further release without patient’s authorization

Bruce J. Sachs, M.D.
A Professional Corporation
501 N. El Camino Real, Suite 100
Encinitas, CA 92024
PHONE: 760-944-6520 FAX: 760-944-6525
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AUTHORIZATION TO RELEASE MEDICAL RECORDS