I request Authorize and Request: (hospital/physician) to release medical information *

I request only the following medical records to be released:

I request ALL pages of available medical records for the treatment date(s) listed below

Information sent to above for the purpose of:*

ATTENTION: Once this information has been released pursuant to this Authorization, it may no longer be protected by Federal and/or State law/regulations and my no longer be deemed “Confidential”. I permit the release of all information indicated above including test results and/or diagnosis and treatment information, if any, concerning drug/alcohol treatment or use, psychiatric treatment or AIDS/HIV and other communicable diseases.

I understand that the releasing hospital, physician or medical clinic, and any of its affiliated healthcare providers, cannot make me sign this Authorization as a condition to getting treatment, making payments on any bills, or gaining enrollment or eligibility in any health insurance plan, unless the federal privacy regulations allow it. I acknowledge that I have received a signed copy of this Authorization, if I elected to obtain one. I know that I may revoke this Authorization at any time but understand that to the extent information has already be released, in reliance on this Authorization, that action cannot be reversed. This Authorization will expire ninety (90) days from the date it is signed if I do not cancel/revoke it in writing prior to the expiration date. I understand that if I want to cancel/revoke this Authorization, I must mail, fax or bring a letter in person stating that I want the cancel/revoke this authorization. I understand that I need to mail, fax or bring the letter to the address or fax number noted at the top of this page. If you are signing on behalf of a patient for who you are the legal guardian or personal representative, you must attach a certified copy of your appointment as legal guardian or personal representative.*