Consent to Release Medical Information

CONSENT TO RELEASE MEDICAL INFORMATION 

Expires: _________________________________________  

Patient Name: _______________________________________ Date of Birth: ______________  

Address:  

______________________________________________________________________________ 

______________________________________________________________________________ 

II. WRITTEN CONSENT SECTION  

I, _______________________________________________ hereby consent to the release of the following information from my medical records by __________________________ 

to ________________________________________________ at the following address: _____________________________________________________________________  

Specific Information to be Released:  

______________________________________________________________________________  

Specific Purpose of Release:  

______________________________________________________________________________  

This written consent is subject to revocation at any time by writing to the physician or practice which is to release the information except to the extent that this physician or practice has already acted in reliance on this consent. With the exception of mental health, HIV-related information or drug &/or alcohol abuse records, once your health information is disclosed, it may be re-disclosed by the recipient and may no longer be subject to state or federal law protections. To revoke this consent, simply sign and date the revocation section on your copy of this form and return it to your physician’s office or, if this authorization is for research, to the Principal Investigator (PI), the primary researcher conducting the study. If you do not have a copy, another copy will be provided. If not previously revoked, this consent will remain in force from ___________________________to___________________________________ the end of which consent expire.  

REVOCATION SECTION(to be completed and signed by the patient):  

This consent expires on (00/00/00):________________________________________________