Patient First Name

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Patient Last Name

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Date of Birth

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Physician or Medical Facility:

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Address:

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Phone:

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Fax:

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Edward R. McCarthy, DO

Jonathan D. Bornfreund, DO

Mercedes Davis, PA-C

Natali Amaradasa, FNP-BC

Radiology (CT, MRI, X-Ray)

Medical Records x 1 year

Continuing Medical Care

Other

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I understand that the information in my medical records may include information relating to treatment of drug or alcohol abuse, mental health, genetic information, sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC) and/or human immunodeficiency virus (HIV).

I understand that I may inspect or copy the protected health information described by this authorization.

I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal and state privacy regulations.

I understand that I may revoke or terminate this authorization by submitting a written revocation to Family Medicine of SayeBrook, LLC.

I understand my records are protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. Federal regulations also prohibit any further re-disclosure of this information by the recipient with which you have consented. I hereby release FMS and any associated staff from all liability or legal responsibilities that may arise from the release of such records.

Relationship of patient representative to patient:

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AUTHORIZATION TO RELEASE INFORMATION

Patient (or patient representative) Signature: