AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION

Patient’s Name: _______________________

Date of Birth: _________________

I request and authorize Gorgin Arasteh, DDS to release health care information of the patient named above to Healthcare Professional/Individual listed below:

Name: ______________________________

Address: _____________________________

City: ________________

State: ________________

Zip code: _____________

I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use, you are specifically authorized to release all health care information relating to such diagnosis, testing, or treatment.

Signature: _____________________________

Date Signed:_____________

Relationship or status if signed by anyone other than the patient (parent, legal guardian, etc.): _______________________________