RECORDS RELEASE

______________________________________________________________

TO:________________________________________

ADDRESS:_____________________________________________

_______________________________________________

I hereby authorize any physician, surgeon, hospital, insurance company, vocational rehabilitation office, or any mental or public health care facility, to release to John Smith, M.D., PA, all medical records or other evidence in their possession regarding my treatment, medical history, hospitalization and/or outpatient care for my condition, including psychological or psychiatric impairment, drug abuse and/or alcoholism, or sickle cell anemia or Acquired Immunodeficiency Syndrome (AIDS) or tests for or infection with Human Immunodeficiency Virus (HIV). A photographic copy of this authorization shall be valid as the original.

Name:__________________________________________________ Date:__________

^{Please print}

Address:_______________________________________________

_________________________________________________

_________________________________________________

SIGNATURE:____________________________________

Witness:________________________________

^{(if relative, state relationship)}

Date of Birth:_____________________

Social Security #: __________________________

Dates of records in your possession from_____________ to _______________.