Medical Records Release – INCOMING

I,   (full name of parent/guardian or self)   authorize

Please initial the line next to the appropriate request. (please initial ONE)
Initial    All of my child's medical records (as of the date of this release)
Initial    All of my child's medical records except the following:   Type a label   
Initial    Only the following information:   Type a label   

This authorization also Specifically allows the release of the following information (this information
WILL NOT be released unless the appropriate line is initialed):

Initial   Any record or treatment for alcohol/or other substance abuse
Initial   Any Record of Mental Health Care (Evaluation, Testing, Treatment and Counseling)
Initial   Any record of testing, treatment, reporting, or research pertaining to infection with HIV, any sexually transmitted or related disease, or pregnancy termination.

This release is effective for 1 year from the date of execution; however, I may revoke it at any time by providing notice in writing to the above-named party.

I acknowledge that a completed copy of this release is available to me through the Patient Portal.

A copy of this form is acceptable authorization for the release of the above described information.

Notices to Person Authorizing Disclosure

Except for certain research purposes, the completion of this authorization is not required prior to the provision of treatment.

The information released pursuant to this authorization may be subject to re-disclosure and may no longer be protected by federal or state privacy laws.