By indicating “Entire Record” all medical information, information regarding any sexually transmitted disease, psychiatric treatment, drug and/or alcohol abuse, HIV testing, ARC and/or AIDS information in my records will be released. If you prefer certain medical information not be released, please contact the appropriate office staff.

**If I fail to specify a date, this authorization will expire in 6 months from the date it was signed. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization in writing, the revocation will not apply to information that has already been released. I understand that once the information has been disclosed, the recipient may re-disclose it, and federal privacy laws may not protect the information.

Fee for copying chart: $1.00 up to 25 pages, .25 cents per page thereafter. Authorization must be signed and payment received before chart will be copied. Please allow 7 to 10 working days to copy chart.