Authorization to Release
1450 East Valley Road, Suite 101
Basalt, CO 81621
Phone (970) 279-4111 * Fax (970) 927-3915
Patient's name: __________________________ SSN: _____-_____-______ DOB: ____-____-____
Name & Address to provide records: Name & Address to receive records:
I authorize the release of the information specified below.
Release these records:
______ 1. Only records generated by this facility (not including records received from other sources)
______ 2. Only some portion of records maintained at facility (specify below)
______ 3. All medical records at this facility
______ 4. Other: __________________________________________________________________
I specifically authorize the release of information regarding the following condition(s):
______ Drug abuse if any
______ Substance abuse if any
______ Psychological or psychiatric conditions if any
______ AIDS/HIV if any
Expiration or revocation of authorization -- I understand that I may revoke this authorization at any time.
Use of copies -- A copy of this authorization may be utilized with the same effectiveness as an original.
Patient’s Name (Print) Patient’s Signature Date
_____________________________________ ____________ ____________________________________
Person Authorized to Sign for Patient (Print) Relationship Authorized Signature Date
Based upon COPIC Form at http://www.copic.com/guidance/release.htm Updated: 23 November 2007