AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION
Patient’s Name: _______________________
Date of Birth: _________________
I request and authorize Gorgin Arasteh, DDS to release health care information of the patient named above to Healthcare Professional/Individual listed below:
Zip code: _____________
I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use, you are specifically authorized to release all health care information relating to such diagnosis, testing, or treatment.
Relationship or status if signed by anyone other than the patient (parent, legal guardian, etc.): _______________________________