Release of medical information authorization

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Amanda E. Williams, M.D., Inc. 5555 Glenridge Connector, Suite 200 Atlanta, GA 30342 Phone 470-575-4321 Fax 459-281-0986
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
I, the undersigned, hereby authorize Amanda E. Williams, M.D. Inc.:*

To Disclose Information to the following person/facility:To Receive Information from the following person/facility:To Exchange Information with the following person/facility:
Person/Facility*
Address of Person/Facility*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Person/Facility*

Area CodePhone Number
Fax Number of Person/Facility

Area CodePhone Number
Email of Person/Facility
example@example.com
Purpose and need for such disclosure:*

Information SharingCoordination of CareAt the request of the patient
Information to be Disclosed (check all areas for which consent is given)*

Diagnostic AssessmentProgress NotesChemical Dependency AssessmentLab test resultsPsychological TestingTreatment Plan/Continuing Care RecommendationOther, please specify belowAll of the previously listed
Other specified information
I understand this Authorization for Release of Information is valid indefinitely, but may be revoked by me at any time, unless it has already been relied upon. I understand that the medical records may contain information pertaining to: Human Immunodeficiency Virus (HIV) test results, Acquired Immune Deficiency Syndrome (AIDS), Drugs/Alcohol Abuse, Psychiatric and Psychological treatment. I consent to teh release of any such information contained in the records designated above. Information disclosed pursuant to this authoriation may be redisclosed by the recipient and no longer protected by federal privacy regulations.
Signature*
Date signed*

MonthDayYear
Date
Should be Empty:

AUTHORIZATION TO RELEASE MEDICAL INFORMATION