Patient’s* Authorization for the Release of Medical Information

I hereby authorize_____________________________ MD, to furnish records and medical information concerning to (name and address of recipient) ___________________________________________________ 

All information about the care and treatment of the above-named patient may be released, including but not limited to information about general medical care, out-patient treatment with a psychotherapist, and substance abuse/chemical dependency treatment, with the following exceptions: _______________________________________________________

PLEASE NOTE: For the release of specially-protected medical information [e.g., federal- or state-assisted drug and/or alcohol abuse treatment records, and HIV test results], the box below must be completed by the patient or his/her representative.

Disclosure of the records/information may be used only for the following purposes: 
______________________________________________________________

I have been advised of my right to receive a copy of this form.

Print Name:_____________________________  Date:____________________ 
Signature: ______________________ This authorization expires on: __________

* If form is not signed by patient, indicate relationship of signer:
__ Parent or guardian of minor patient (for care for which the minor was not permitted to consent).
__Guardian or conservator of an incompetent patient.
__ Beneficiary or personal representative of deceased patient.
__ Spouse or person financially responsible (solely when information is needed to process application for dependent health care coverage.)

Special Authorization for the Release of 
Specially-Protected Medical Information

I authorize release to the above-listed recipient the following records concerning the patient designated above.

______Drug and/or alcohol abuse records of federal- or state-assisted programs.
Initials 

______HIV test results.
Initials


Print Name: ________________________________
Date: __________________
Signed: ___________________________________
            Patient or authorized representative