My Full Name Is: *

And i authorize PHTC, Inc., to disclose the following information from the health records of:

Patient Full Name *

Date of Birth *

Address *

Telephone *

Social Security Number *

Covering the period (s) of healthcare:

From Date: *

To date *

Information to be disclosed: *

Complete health records
Discharge Summary
History and Physical Examination
Consultation Reports
Progress Notes
Laboratory Tests
X-Ray Reports
Photographs, videotapes, digital or other images

Other (Please specify)

Please note that a special release form needs to be signed for release of HIV results.

This information is to be disclosed to *

For the purpose of *

I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization.Unless otherwise revoked, this authorization will expire on the following date, event or condition:

The facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above in information to the extent indicated and authorized herein. *

I Agree