I hereby authorize *

Phone *

Fax

to disclose / release the complete health records of the patient identified below to:

DR.

Patient Name *

D.O.B.

SSS#

Phone Number *

I understand this disclosure may include information relating to any of the following: AIDS, HIV, Psychiatric care, and treatment and/or test relating to alcohol and /or substance abuse. The purpose of this disclosure is for continuing medical treatment.

I understand this authorization may be revoked in writing at any time, except to the extent that the action has been taken in reliance on this authorization. Unless otherwise revoked, this authorization will expire ONE YEAR after the date signed, or the following the event of

Condition:

The facility, its employees, officers and physicians are hereby released for any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein.