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AUTHORIZATION TO BEAVER RECEIVE OR RELEASE …

AUTHORIZATION TORECEIVE OR RELEASEMEDICAL INFORMATIONI hereby authorize BEAVER medical Group to disclose or RECEIVE the following information fromthe health records of the patient listed below:PRINT CLEARLY:Purpose of Disclosure: Personal Access Continued Care Other (Describe)_____A separate AUTHORIZATION is required to authorize the disclosure or use ofpsychotherapy notes and HIV test type of records and the dates of service to be released or disclosed is as follows( ) check all that apply: Entire record (including Alcohol/drug treatment information ) Entire record (excluding Alcohol/drug treatment information ) Billing information Problem list Medication list Immunization records Laboratory results X-ray reports Mental health records (excluding psychotherapy notes) Other diagnostic (specify)_____ Other_____ Limitation of release_____Date(s) of Service _____I understand that the information in my health record may include information relating tosexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or humanimmunodeficiency virus (HIV).

AUTHORIZATION TO RECEIVE OR RELEASE MEDICAL INFORMATION I hereby authorize Beaver Medical Group to disclose or receive the following information from the health records of the patient …

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