Medical Record Release Form

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Authorization for Release of Medical Information

Patient Name: 

Date of Birth:

Telephone Number:

Last 4 digits of Social Security Number:

I hereby authorize:

Andrea Lightbourn MD PO BOX 2179 Southfield, Mi 48037 248-356-0337 (fax) 

To release information in my Medical Records:

Including information about communicable diseases and infections (as defined by statute and Michigan Department of Public Health rules). Which include sexually transmitted diseases, tuberculosos, hepatitis B, HIV-human immunodeficiency virus. AIDS-aquired immunodeficiency syndrome and ARC-AIDS related complex. Alcohol and Drug abuse treatment information. Mental health treatment records, psychological services and social services information communications made to a social worker or psychologist.

I authorize such disclosure to the individuals or organizations listed below:

Name:

Address:

City:

State:

Zip Cose:

Telephone Number:

Fax:

Specific type of information to be disclosed:

[] Pap test   [] Mammogram Reports [] All progress reports  [] Lab reports  [] X-ray Reports

[] All information   [] Other __________________________________________________

Purpose of need for such disclosure:

[] Continuing Medical Care  [] Personal   [] Payment of Insurance Claim

[] Other__________________________________________________

This authorization is subject to written revocation at any time except to the extent that action has already been taken in reliance on the authorization. If not previously revoked, this authorization will terminate in six (6) months from the date of the signature.

Signature of Patient ______________________________________  Date______________________

(Or Parent/Guardian/Authorized Representative)

• Signature of Witness ______________________________________ Date______________________