You are hereby authorized and directed by the undersigned to give to the bearer of this authorization, or any photo static copy thereof, any and all information relative to the undersigned and named applicant's physical, emotional, and mental condition and permit the bearer to examine x-rays, laboratory reports, and medical records of any kind of which reflects diagnosis, treatment, prognosis, and any other information concerning illness, injuries, or disability. Such information shall specifically include, but is not limited to, itemized billing records/statements, history & physical, operative reports, lab/pathology reports, consultation reports, physicians' orders, discharge/death summary, x-ray reports/images, other radiographic reports/images, emergency room records, face sheets, nurses' notes, flow sheets, pharmacy and medication records, care plans, assessment tools, screening tools, summaries, social workers, legal, and monitor strips, readouts or printouts. I understand that the specified information to be received/released may include, but is not limited to: history, diagnosis and/or treatment of drug or alcohol abuse, mental illness, psychological and/or psychiatric treatment, counseling records/note, genetic testing or communicable disease, including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS You are hereby authorized and directed to make available all such information for inspection and copying.
DURATION OF THIS AUTHORIZATION:
This authorization expires one (1) year from the date signed.