Medical Records

Patient Information

* Indicates required field

You may release my information FROM:

You may release my information TO:

Information to be released: *




Purpose for which information is being released (check one): *

Patient Authorization:

I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.

This authorization, unless expressly limited by me in writing, will extend to all aspects of treatment, including testing and/or treatment for sexually transmitted diseases, AIDS, or HIV Infection, alcohol and/or drug abuse, and mental health conditions.

My Rights:

I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization, please read the Privacy Notice to patients posted at the facility where your information is being released. I understand that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization may re-disclose it, at which time it may no longer be protected under Privacy laws.

This Authorization will expire on:

If no date/event is given, the authorization shall expire 90 DAYS from the date signed

*Possible copying fee required

Signature *

Photo Id *

We require photo identification to ensure the validity of the request. Please upload a photo/ scanned image of your driver license or legal picture identification. For release of information purposes, your photo ID will not be released outside of WCPM

Date

05/29/2017