AUTHORIZATION FOR RELEASE OF INFORMATION

Consent for Release of Medical Records

Name of Patient: _____________________________ Date of Birth: __________________

The patient above is requesting a copy of his/her records to be sent to:  Vistas Medical Center, 5329 Memorial Drive, Suite A, Stone Mountain, Georgia 30083.

I, ____________________________am authorizing my medical records to be released to the above-mentioned Doctor/Hospital/Facility. I do hereby consent and authorize the office to release copies of my medical records, including current and previous medical records from other practices and practitioners, hospitals, and/or clinics which are a part of my medical records. PLEASE NOTE: This authorization includes consent for release of alcohol, drug, psychiatric and psychological information and any other information relating to pregnancy, sexually transmitted diseases, HIV testing, AIDS, and AIDS-related syndromes. I agree that a copy of this release or fax of this release shall be as valid as the original release. Please send copy of all required information as soon as possible via fax or to the address listed above.

Patient’s Signature: _____________________________________