Patient Name:_______________________________  Date of Birth:_______________________

Social Security Number:______________________   ComCare Physician:_____________________

1. I authorize the use or disclosure of the above named individual's health information as described below.

2. The following individual(s) or organization(s) are authorized to make the disclosure:

3. The type of information to be used or disclosed is as follows (check the appropriate boxes and include other information where indicated)
o     Entire record
o     Medication list
o     List of allergies
o     Immunization records
o     Lab results (please describe the dates or types of lab tests you would like disclosed)
o     X-ray and imaging reports (please describe the dates or types of x-rays or images)                                                                                                                                              
o     Other (please describe):_______________________________________________

4. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

5.  The information identified above may be used by or disclosed to the following Comcare Physician:
ComCare Physician:  _________________________
  ComCare Elm Street—617 E. Elm Street    Salina, Ks 67401  Fax:  785-823-0177
  Comcare Santa Fe—520 S. Santa Fe, Ste. 300    Salina,  Ks 67401  Fax:  785-823-0506

6.  Request records from previous physician (only one physician per release unless all in same clinic):
Name: __________________________________    Phone: _____________________________   Fax: ___________________
Address (City, State, Zip): __________________________________________________________________________________

7.  This information for which I'm authorizing disclosure will be used for the following purpose:

 My personal records

 Transfer of Care

 Attorney/Court Case

 For Primary Care Physician Records

 Other:_______________________________________________

8.  I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment.

_______________________________________     ____________________    ___________________________
Signature of patient or legal representative                                     Date                                                   Witness

If signed by legal representative, relationship to patient  ____________________