I have carefully read and understand the above statements and do herein expressly and voluntarily consent to disclosure of the above information about, or medical records of, my condition.

I hereby release the above named keeper of the records from all liability that may arise from the release of these medical records. I understand that any person or organization to whom my records are disclosed may re-disclose this information if legally mandated.

I understand that this consent is subject to revocation at any time in writing, unless action has already been taken in reliance upon it. This authorization will expire 1 (one) year from the date shown below unless otherwise stated here.

Email Address:
Name:		DOB:
Address:
City:
State:
Zip:

Initials:		I authorize the release of drug abuse, alcohol abuse, sexually transmitted disease and/or psychiatric records.
Initials:		I authorize the release of my HIV test results. I have read this consent form, have asked all questions I have about the reason for the release of my HIV test and I agree to the release of all this information.

Signature of patient, responsible person, or legal guardian (if minor):*	Date:

Witness:	Date:

I hereby authorize and consent to the release of medical records obtained in the course of my treatment at:
for the purpose of: