Authorization for Release of Medical Information

Patient Name: Last First MI: Date: 05/11/2008

Patient Address:

Phone () Date of Birth: / /

Present Physician:

Present Physician Address:

Information to Be Released:

Entire Medical Profile

A Specific Portion of the Record: From date of service to

Please indicate any limitation on the information to be released (information not to be released)

This information may include the following, unless identified immediately:

(a) Alcohol or drug abuse, or mental health treatment information protected under Title 42 of the Code of Federal regulations part II.

(b) Serious communicable and infectious diseases as defined by the Michigan Department Of Community Health code, 1989, act 174, which includes Venereal Disease, Tuberculosis, Human Immunodeficiency virus (HIV), Acquired Immunodeficiency syndrome (AIDS), AIDS- Related complex (ARC), and hepatitis.

(c) Records and reports sent to our office or Dr./Drs. Employed by Munson Medical Center, from other physicians, clinics, hospitals, or other health , medical, or human service providers.

Revocation of this consent is available at any time, except to the extent that the release of the information has already occurred in reliance upon this consent.

The duration of this consent without express revocation shall expire in 180 days from date signed.

Release the Information to the Following:

New Physician:

New Physician Address:

Attention: Phone ()

Purpose:

I authorize and request that any and all medical information as indicated above be released according to the term outlined within this agreement.

Authorizing Signature	Witness
Print Name and Relationship to Patient Witness	Witness: Please Print Name
Date
Copyright protected. See Registration page.