Patient Name:        Date of Birth: (sample mm/dd/year )

Social Security #:       

Date (s) of Treatment/Hospitalization: 

1.       2.    

3.       4.

5.       6.

INFORMATION TO BE RELEASED: 

   History and Physical                               Mammograms                               Laboratory Studies

   Medication Lists                                     Ultra-Sounds                                 ER/PR Reports

   Operative Reports                               Other reports not listed  

I Herby Authorize the Following Physician or Facility:  

Name:

Address:

City:    State:     Zip: 

Phone:          Fax: 

To release all of the above requested information relative to my treatment and care, I understand that I may revoke this authorization at any time by providing written notice of revocation, except to the extent that action has already been taken. This authorization shall be considered invalid after six months, or 60 days. The undersigned herby authorize release of records/information, which may include:

ALCOHOL, DRUG USE AND/OR PSYCHIATRIC ILLNESS, HIV, HIV RELATED ILLNESS, AIDS/OR AIDS RELATED ILLNESS, AND HEPATITIS  RELATED ILLNESS’S.  

Signature of Patient and/or Signature of legally authorized representative:

Printed Name:                  Date:  (sample mm/dd/year )

Written Signature: 

Please type in your full name. You will be asked to sign this form  when you  arrive at the clinic.