_________________ (“Patient”) of __________________________________(Address), with ID Number ___________________, hereby authorizes the release, disclose, and delivery of the medical information described below to: _______________
Specific Authorization. I specifically authorize the release of all medical information relating to the above-named patient including but not limited to the following categories protected by state or Central law: (1) Substance abuse (drug or alcohol) treatment (2) Mental health treatment and (3) HIV-AIDS-related information, if such information is contained in the records. This request includes any reports, correspondence, test results, and any other information contained in the records, whether generated by the authorized provider or another entity.
I do not give permission for any other use or redisclosure of this information.
Yours very truly,
Patient Redisclosure. This release does not authorize redisclosure of medical information beyond the limits of this consent……
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