*If patient is unable to sign, a copy of the legal documentation for patient’s representative must be supplied with a copy of this form.
Information is to be Released to:
Information to be Released (If you fail to specify, a 1-year abstract of records will be provided)
Please select all that apply.
I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS Information.
Except to the extent that action has already been taken in reliance on this Authorization, you have the right to revoke this Authorization by submitting a notice in writing to the Department of Health Information Systems or other Department to whom you are authorizing disclosure. Unless revoked, this Authorization will expire in 90 days from date of signature.
*Please confirm that you have carefully filled out this form in its entirety. If incomplete, we may not be able to fulfill the request.
A copy of the patient's drivers license or other valid documentation (such as patient release documentation, letter of representation, etc.) is required for processing.