AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I hereby authorize , M.D. to furnish medical information
concerning (patient) to
(name and address of person to receive records).
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:
The information may be used only for the following purposes:*
This authorization is effective now and will remain in effect until (date).
I understand that I have the right to receive a copy of this authorization.