Authorization to Use/Disclose Health Care Information

Patient Name: _________________________________________ Birth date: ________________

Maiden or other name (if applicable)___________________________________________

I request and authorize Edward Elliott, M.D. to release the health care information described below to:

Name: ______________________________________________ at ________________________

Address: ______________________________________________________________________________

City, State: _____________________________________ Zip code: ______________

This request and authorization applies to only the following protected health information:

_______________________________________________________________________________________

_______________________________________________________________________________________

during the following time period or dates: ___________________________________________________

Purpose(s) of this use/disclosure: ______________________________________________________________________________

Authorization expires: ______________________________________________(date or event)

I understand that, unless action already has been taken in reliance on this authorization, I may revoke this authorization at any time by making a written request to Edward Elliott, M.D.

I understand that Dr. Edward Elliott may not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization, unless my treatment is related to research and the purpose of this authorization is to enable the protected health information described above to be used for such research.

I understand that information disclosed based on this authorization may be subject to redisclosure by the recipient, and no longer protected by federal privacy regulations.

I understand that my express consent is required to release any health care information relating to testing, diagnosis and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health or drug/alcohol treatment or use.

Signature (patient or authorized representative)__________________________________________________________________

Date: ________________________________