EmailMe Form - MEDICAL RECORDS RELEASE AUTHORIZATION

Patient Name *

First Middle Last

Patient Previous Name(s)

Patient Date of Birth *

MM / DD / YYYY

Patient Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

I understand this acts as written authorization for Generations OB-GYN to release medical information to the Named Patient -OR- Physician *

YES

Named Patient -OR- Physician Contact *

Named Patient -OR- Physician Contact Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Named Patient -OR- Physician Contact Phone *

### - ### - ####

Named Patient -OR- Physician Contact Fax *

### - ### - ####

Required By Date *

MM / DD / YYYY

Information to be released *

If other, please be specific

Purpose of disclosure *

If other, please be specific

HIV/AIDS DISCLOSURE: I consent to the release of any positive or negative test results for AIDS or HIV infection, antibodies to AIDS,, or other infections with any causative agent of AIDS with the rest of my medical record *

Yes

No

Type your name in the box. This acts as an electronic signature. I understand that according to the rules set by the Michigan Board of Medical Examiners, Generations OB-GYN has 15 business days from the date this form was received to provide me with an exact copy of the above requested information within my medical record. I am also aware that a fee may apply for the request and is SOLELY my responsibility. *