Patient name:
Date of Birth:
Address:
Phone Number:
Treatment dates from:
to:
I authorize: (enter your current physician’s information)
To release copies of my medical records to: (enter your new physician)
Mental Health - YesNo
HIV/AIDS - YesNo
Substance Abuse - YesNo
Communicable Disease - YesNo
All - YesNo
Only the following:
I understand that this information shall be in effect for 365 days following the date of signature. However, I understand that this authorization may be revoked at any time by giving written notice to the medical office. A photocopy of this authorization shall constitute a valid authorization. I understand that once my medical records have been released, the medical office cannot retrieve them and has no control over the use of the already released copies.
I hereby release Rupinder Maan, MD from any and all liability which may arise as a result of my authorized release of records.
Should my case require review by a governing agency or another medical profession actively involved in my care to make a final determination, it is with my consent that a copy of these records will be submitted to the agency or medical profession for this review.
Patient (or legal representative):
Date:
Relationship to Patient:
Witness:
NOTICE: The information has been disclosed to you from records whose confidentiality has been protected by federal and state law. You are prohibited from making further disclosures of such information without specific consent of thezzerson to whom such information pertains or as otherwise permitted by state law. A general authorization is not sufficient for this purpose.