Records Release

AUTHORIZATION TO RELEASE

HEALTHCARE INFORMATION
Patient's Full Name
Previous Name
If Applicable
Date of Birth

MonthDayYear
Date
Who is the other Doctor/Practice you are requesting information from?
Name of other healthcare practice/Doctor (not Dr. Neil)
This request and authorization applies to:

Healthcare information relating to the following treatment, condition, or dates:
I authorize the release of my STD results, HIV/AIDS testing, whethernegative or positive, to the person(s) listed above. I understand that theperson(s) listed above will be notified that I must give specific writtenpermission before disclosure of these test results to anyone
I authorize the release of any records regarding drug, alcohol, or mentalhealth treatment to the person(s) listed above
Patient Signature
Today's Date

MonthDayYear
Date
THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.
Should be Empty: