AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

In an effort to avoid duplication, and thereby help control costs, I hereby authorize
and request

(Physician of medical group)

To release the following information contained in my records, including information

about Human Immune Deficiency Virus Positivity (HIV+), Acquired Immune
Deficiency Syndrome (AIDS), and AIDS- Related Complex (ARC), as defined by the
Ohio Department of Public Health.

Patient Name Date of Birth

History and Physical X-ray/MRI Report

Laboratory Reports Surgery Report
Pathology Reports Progress Report
Audiology Reports All Medical Records
Discharge Summary Treatment Summary
Other

To:

I understand that I may revoke this authorization at any time, and that it automatically expires once that
purpose for which it was intended is accomplished. My signature means that I have read this form
and/or have had It read to me and explained in a language that I can understand.

Signature of Patient, Parent, or Guardian Today’s Date