Date
Patient Name
Date of Birth
Address
I hereby authorize:
Marjaneh Rouhani, MD 300 Country Pine Lane Battle Creek, MI 49015
To release to:
Name of Person or Agency
Information to be disclosed:
All medical information
Specific medical information
Please describe:
Purpose and need for such disclosure:
I hereby consent to the release of any medical information, which may include the following: psychiatric, alcohol and/or drug abuse records, AIDS, AID-related complex (ARC) and HIV infection. I understand that this authorization may be withdrawn by me at any time. Revocation of this authorization will not affect any information already released.
Patient Signature
Witness
