*Note: If these records contain any information from previous providers or information about HIV/AIDS status, behavioral or mental health services, cancer diagnosis, drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this information.

These records are for services provided on the following date(s):

Please send the records listed above to:

Release to first contact

Release to second contact:

The information may be used/disclosed for each of the following purposes:

This authorization shall expire no later than: or upon the following event (whichever is sooner), and may not be valid for greater than one year from the date of signature for Maryland medical records. I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by law. By signing below I represent and warrant that I have authority to sign this document  and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.

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Signature of patient (or patient’s personal representative)

Please sign below using mouse or track pad on desktop/laptop; or via stylus or finger on tablet or mobile device.

Reset Signature

Date:
 

You have the right to revoke this authorization, except to the extent the custodian of records has relied on it, by sending your written request to the Privacy Officer, Maryland Pain Specialists, 8322 Bellona Avenue, Suite 330, Towson, MD 21204. Phone: 410-825-6945 option 9 ; Fax: 410-825-8974