Authorization to Release Medical Records

Please complete this form to authorize the release of your medical records.

I Hereby Authorize

Authorized Parties to Release Records:

Name	Fax	Phone

Timeframe of Request:

All RecordsRecords From Start Date To End Date

To disclose records to:

Bruce J. Sachs, M.D.

A Professional Corporation

501 N. El Camino Real, Suite 100

Encinitas, CA 92024

PHONE: 760-944-6520

FAX: 760-944-6525

Information Release Authorization

I wish to limit the type of information released

Unless otherwise indicated above, authorize release of:AIDS or HIV testing informationPsychological or psychiatric treatment informationAlcohol or drug abuse information

This consent is subject to written revocation at any time except to the extent that action has been taken. If not earlier revoked, this consent shall become invalid one year from the date of signature.

I hereby release all parties from any/all legal liability that may arise from the release of this information.

Patient Information

Patient Name

Date of Birth (MM-DD-YYYY)

Primary Phone

Signature

Signature (Signature of Patient/Spouse/Parent/Guardian/Conservator/Legal Representative)

Date (MM-DD-YYYY)

If signed by other than patient, indicate relationship:

IMPORTANT: