Medical Records Release Form

Patient Name (First and Last)*

Maiden/Other Name

Date of Birth*

Date

Phone Number*

Street*

City*

State*

ZIP*

Requested Records:

If marked other:

Where are we requesting records from?*

Name of practice/person receiving requested records:

By signing this form, I am authorizing to release any and all information contained in the record which may include information regarding: Drug and/of alcohol treatment, psychological records, HIV/AIDs and other sexually transmitted diseases. I understand that, as set forth in the practice's Notice of Privacy Rights, I have the right to revoke this authorization, in writing, at any time by sending written notification. I understand that a revocation is not in effect to the extent that the practice has relied on the use or disclosure of the protected health information. *This authorization will expire 1 year after the signed date.*

Patient Signature*

Date*

Date

Authorization for Use or Disclosure of Information