Authorization to Release Medical Records
TO:
This letter will authorize you to provide a copy of my medical records to White Rock Orthopedic Association, Drs. Marc S. Goldman and Robert A. Goldberg. At this time I am requesting the following: (Please check one of the following)
__________Complete record
__________ Records of care from _____________________ to ________________ only
__________ Records of care concerning the following condition(s)
______________________________________________________________________________
__________ Other. Specify:_______________________________________________________
__________Confer with other person orally about information in my medical record
|
HIV/AIDS. I consent to the release of any positive or negative test result for AIDS or HIV infection, antibodies to AIDS, or infection with any other causative agent of AIDS, with the rest of my medical records. Initial
Date
_________________ |
Please forward the information to:
White Rock Orthopedic Association
The reasons or purposes for this release of information are:
I understand that you will provide this information within 15 business days from receipt of this request.
Signed: ____________________________________________________ Date: ____________
(Patient or person legally authorized to
consent on patient's behalf)
__________________________
Please Print Patient’s Name Here