Consent for Release of Information

Patient Name*

Facility/Doctor*

Other Names

Address

Date of Birth *

SSN*

Phone*

Fax

From - I hereby authorize the above identified provider to release to St. Paul Rheumatology, P.A., information from my medical records.

To - I hereby authorize St. Paul Rheumatology, P.A. to release to the above identified provider, information from my medical record.

This consent to release information is limited to the following:

Medical records regarding treatment for

(Medical condition or injury) occurring on or about

Including

Not including records related to alcohol and/or drug abuse treatment, psychiatric records and/or records relating to communicable diseases.

I understand that I may revoke the consent at any time. This consent will expire one year from the date of my signature.

I understand that one information is released pursuant to this authorization, the hospital/clinic, their employees and my physician(s) cannot prevent the redisclosure of that information. I hereby release each of them from any and all liability arising directly or indirectly from disclosure authorized by this consent and any redisclosure of the information. Saint Paul Rheumatology will not condition treatment on whether I sign this authorization.

Signature of patient*

Relationship to patient if signed by guardian

Date of Signature

Reason patient unable to sign