Medical Records Release

and all employees, contractors, and associated individuals thereof;

do hereby request the following information be released:

Medical Records

1. All medical and health information contained within:
a. Charts;

b. Notes;

c. Reports;

d. Records;

e. Medication lists, and other lists;

f. Prescriptions

g. Flowcharts;

h. Emails;

i. Memorandum;

j. Orders;

k. Lab results;

l. Test results, and analyses:

m. Information related to treatment for any sexually transmitted disease, including HIV or AIDS;

n. Information related to treatment for mental health illnesses; o. Information related to treatment for substance abuses; p. Diagnostic images and reports, including but not limited to X-rays and EKG tracings;

q. Photographic images, and

r. Digital recordings, including but not limited to digital images.

1.2 All information related to the accounting of the Patient's files, including but without limitation to Statements of Account.

1.3 All other authorizations previously received for the release of any or all of the Patient's medical information.

1.4 All of the above is collectively referred to as "Medical Records", as represented on paper, kept in folders, or stored digitally, electronically, or any other form.

1.5 "Medical Records" also includes production of any documents or material by physicians, nurses, chiropractors, dentists, therapists, counselors, consultants, technicians, and any and all staff of the organization to which this Release is directed.

2. I ask that Patient's Medical Records be released to me, for my own personal use.

2.2 I am aware of the potential for information disclosed pursuant to this Release to be subject to redisclosure by me and so may no longer to be protected.

3. I ask that the Patient's Medical Records be released within the next 30 days as required by the Health Insurance Portability and Accountability Act.

4. The contact information and particulars of the Patient are as follows: