AUTHORIZATION FOR RELEASE OF INFORMATION

Patient's Name: _______________________________ Birth Date: / /

I, the undersigned, hereby authorize and request Medical Arts Associates, Ltd. to release to:

Name Address City State Zip

the following information:

[ ] General Medical Information

[ ] Lab & X-Ray Data

[ ] Reports From Other Facilities or Physicians

[ ] Other (specify if only partial info/specific dates are needed) __________________________________

Such information disclosed or delivered may include complete case history as shown by the records, and any

other information in your possession relating to (my/his/her) treatment or condition. I understand I have the

right to inspect the information to be disclosed.

x ________ _____/____/______

(Signature) (Date)

_______________________________________________________________________________________

(Address) (City) (State/Zip)

_______________________________________________________________________________________

(Relationship, if not patient) (Witness)

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SPECIFIC AUTHORIZATION FOR RELEASE OF MENTAL HEALTH INFORMATION

AND/OR DRUG ABUSE INFORMATION AND/OR HIV INFORMATION

In addition to the above information, please release the following:

[ ] Mental Health Treatment

[ ] Drug or Alcohol Abuse

[ ] HIV Related Information

I acknowledge that data to be released MAY INCLUDE material that is protected by Federal Law and that is applicable to EITHER Mental Health Information or Drug/Alcohol Abuse or HIV information. My signature authorizes release of all information (as specified above).

x / /____

(Signature) (Date)

In order for protected information to be released, you must sign the

SPECIFIC AUTHORIZATION RELEASE.