I hereby authorize __________________________________, M.D., to furnish medical information concerning _______________________________________ (patient’s name) to Dr. ___________________________________________________________________________
_____________________________________________ (physician’s name and address).
Any and all information may be released, including, but not limited to, mental health records protected by the Lanterman-Petris_Short Act, drug and/or alcohol abuse records, and/or HIV test results, if any, except as specifically provided below:
______________________________________________________________________________
______________________________________________________________________________
[Optional: I understand and agree to pay a reasonable charge to cover the cost of the transfer. I understand the costs will be computed based on a copying fee of $.25 per page for standard documents, actual costs for the reproduction of oversized documents or documents requiring special processing, and reasonable clerical costs for locating and making the records available.]
This authorization is effective now and will remain in effect until
________________________________ (date).
I understand that I may receive a copy of this authorization.
Signed: _____________________________ Date: _______________________
If not signed by the patient, please indicate relationship:
[] parent or guardian of minor patient
[] guardian or conservator of an incompetent patient
[] beneficiary or personal representative of deceased patient*
Note To be valid, this authorization must be handwritten by the person who signs it or in typeface no smaller than 8-point type (this is 8-point type). It must be clearly separate from other language on the page and executed by a signature, which serves no purpose other than to execute the authorization.
* It is unclear whether the beneficiary or personal representative of a deceased patient can obtain and disclose certain specific records, such as the patient’s mental health records and/or HIV test results.