Existing Patient Request

Patient First Name(Required)

Patient Last Name(Required)

Date(Required)

Patient Phone(Required)

City(Required)

State(Required)

Zip(Required)

I authorize the release of medical information as indicated below:

To(Required)

Physician(Required)

Address(Required)

Phone(Required)

Fax

Email(Required)

If other, please specify

Including, if applicable, the following health information related to testing, diagnosis, and/or treatment for (please type your initials in the applicable below)

HIV (AIDS virus)

Sexually Transmitted Diseases

Mental Health

Drug and/or Alcohol Abuse

Cover the period(s) of care: from

to

Conditions: We may not condition your right to receive health care services from us upon your signing this authorization. However, if the treatment to be provided is for research purposes, your failure to sign this authorization will prevent us from providing such treatment.

Further Uses & Disclosures: When we use or disclose your health information to other parties as you have instructed in this authorization, we will not have the ability to monitor whether your health information may be further used or disclosed by such parties. In such a situation, your disclosed health information may no longer be priced by federal and state privacy laws.

Revocation: You have the right to revoke this authorization at any time by providing us with written notice by certified mail, fax, or hand delivery to the medical records department of custodian with whom the original authorization was submitted. When we received your revocation, we will immediately stop using or disclosing the health information you authorized us to use and disclose in this authorization form. Your revocation shall not apply to those uses and disclosures we made on behalf pursuant to this authorization prior to the time we received your written revocation.

Expiration Date

Expiration: This authorization shall expire upon the earlier of the date you select or one year from the date of this authorization. After the expiration date, we will need to obtain a new authorization from you if required by law.

Disclosure Format & Delivery Method

Electronic and Encrypted Email:(Required)

Electronic via Fax to(Required)

Paper - Please Mail to(Required)

Paper - I will pick up at(Required)

By signing below, you acknowledge that this is a signed, legal authorization.

NOTE: If signed by someone other than the patient, we need written proof of your authority.

Patient Name(Required)

Date of Birth(Required)

Today's Date(Required)

Address(Required)

Email Address(Required)

Legal Signature(Required)

Relationship(Required)