Medical Records Request Form

This written request for the release of medical records is valid for 12 months from the date of my signature unless revoked in writing by me or my authorized agent. I agree to hold both the sending and receiving parties to this request harmless from any and all costs, liability and damages of any nature resulting or indirectly from the release of my medical records. I understand that the information released may include sensitive information related to behavior and/or mental health, drugs and alcohol(including records of a program that provides alcohol or drug abuse diagnosis, treatment or referral, as defined by federal law at 42 C.F.R part 2), HIV/ AIDS and other communicable diseases, and genetic testing