To ensure that your medical records are held in the upmost confidentiality, please be as explicit as possible as to where you want them sent.
Physicians Name: <br/>Practice Name: <br/>Practice Address: <br/><br/>Practice Phone: <br/>Practice Fax:
* Records to be released:
I understand that my medical records are protected under state and federal confidentiality regulations. Disclosure of information regarding drug an/or alcohol abuse and treatment, confirmed sexually transmitted infections (including testing or treatment for HIV/AIDS), and diagnosis of mental illness or psychiatric care cannot be released without my written consent. Please check below if you DO NOT want any of the following records released. All applicable records will be released if nothing is marked.
This consent can be revoked by me at any time unless action has been taken in reliance on it. If not previously revoked, this consent will terminate in 90 days.
* Ten cents per page for medical records, when printed.
* Free doctor to doctor requests, faxed.
