Release of Information Form and Missing Charts

(Patient) (Birth date) (Address)

for the purpose of_______________________________________________________________

This consent is valid until_____________________

(Date)

I understand:

I have the right to inspect and copy the information to be disclosed.

I have the right to revoke this consent at any time.

Revoking this consent shall have no effect on disclosures made before the withdrawal of consent.

The information obtained as a result of this release may not be re-disclosed unless I specifically consent to it.

It has been explained to me that if I refuse to consent to this release of information, the following are the consequences (specify):

N/A

___________________________ ____________________________ ______________________

Signature of Patient Address Date

___________________________ ____________________________ ______________________

Signature of Witness Address Date

* Recipient and Parent/Guardian must sign if recipient is under the age of eighteen*