HIPAA

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

PATIENT INFORMATION

Patient's First Name

Patient's Last Name

Date of Birth

Previous Name:

Social Security #

I request and authorize

to release healthcare information of the patient named above to:

CENTRAL MARYLAND ORAL AND MAXILLOFACIAL SURGERY, PA
10710 CHARTER DRIVE, STE 330 COLUMBIA MD 21044
FAX 410-997-0807

This request and authorization applies to:

Healthcare information relating to the following treatment, condition, or dates:

All healthcare information

Other

Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.

I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

Yes No

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

Yes No

FORM COMPLETED BY

Patient Signature

Clear

Clear

Date Signed

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

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