Authorization to Release Medical Records

Dear Dr. ____________________________: Date: _____________

This letter will authorize you to provide a copy, summary, or narrative of my medical records (as indicated by the check mark(s) below) or to otherwise release confidential information. At this time I am requesting the following:

__________ Complete record

________ Records of care from _____________ to _____________ only

__________ Records of care concerning the following condition(s)


__________ Other. Specify:

__________ Confer with other person orally about information in my medical record to the following person(s):
Name & Address for Records to be sent:

The reasons or purposes for this release of information are:

HIV/AIDS. I consent to the release of any positive or negative test result for AIDS or HIV infection, antibodies to AIDS, or infection with any other causative agent of AIDS, with the rest of my medical records.