I, hereby authorize,DR.Hernandez; Sarah Army, Pa-c; Rebekah James, PAC; and Lynnzie Kipp, PA-c to release medical, Psychiatric, alcohol and/or drug abuse, HIV testing. ARC and/or AIDS diagnostics, eating disorder information, or any other records of a sensitive nature to:

I understand that this consent is revocable upon written notice to DR. Hernandez; Sarah Army, PA-C Rebekah James, PA-C; or Lynnzie Kipp, PA-C except to the extent that the action has already been taken on this authorization. This authorization shall remain in force untilor for reasonable time to accomplish the purpose for which it given. Alcohol and drug abuse information, if present, will be disclosed from records whose confidentiality is protected by Federal Law which prohibits any futher, disclosure without specific written authorization of the undersigned, or as otherwise permitted by such regulations.
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*When obtaining records from these office there is a nominal copying fee of $1.00 per page for the first 25 pages, then $0,25 per page thereafter. If it is necessary to go to storage a flat rate of $25.00 will be charged to obtain the records, in addition to a $0.25 per page copying fee.

I, hereby authorize ,to release medical, psychiatric, alcohol and/or drug use, HIV testing, ARC and/or AIDS diagnostics, eating disorder information or any other records of sensitive nature to:

I understand that this consent is revocable upon written notice to DR. Hernandez except to the extent that the action has already been taken on this authorization. This authorization shall remain in force untilor for reasonable time to accomplish the purpose for which it given. Alcohol and drug abuse information, if present, will be disclosed from records whose confidentiality is protected by Federal Law which prohibits any futher, disclosure without specific written authorization of the undersigned, or as otherwise permitted by such regulations.
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