I Voluntarily authorize Dr. (please choose Dr. name)
Doctor's Name: Stuart N. Seidman, MD Edward Nunes, MD Gregory H. Pelton, MD Gaurav Patel, MD, PhD
from West End Medical Associates to:
Written and/or verbal information from the record of:
This information is to be used for the purpose of:
Specific Information to be released:
I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS information. ______ (please type your initials)
I may refuse to sign this authorization and my treatment will not be conditioned upon signature of this authorization (except for non-health related services such as pre-employment testing, life insurance exams, or drug screenings).
I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices.
If the requestor or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed.
I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it.