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:*

All healthcare informationHealthcare 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*

YesNo
I authorize the release of any records regarding drug, alcohol, or mentalhealth treatment to the person(s) listed above*

YesNo
Patient Signature*

Clear
Today's Date

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