AUTHORIZATION FOR RELEASE OF INFORMATION MEDICAL AND BILLING
Copies of my medical records, including any information regarding medical, psychiatric, alcohol, drug testing or treatment, AIDS, AIDS –related complex (ARC), HIV infection or billing summaries related to any such conditions, are requested and authorized to be released.
This Release is subject to such limitations as indicated below
I understand that I have the right to revoke this consent at any time unless information has already been released in reliance upon my previous consent. Submitting a written notice of revocation to the releasing party may revoke my consent. I understand this authorization is only valid for the date of signature and prior; no future dates or records will be released.
I hereby release, its employees, staff, and agents from any liability which may arise as a consequence of the disclosure of the information set forth above relating to my medical/billing records.
Any subsequent disclosure of medical/billing information by the recipients is prohibited without the express written consent/authorization from the above-named patient/guardian.
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