Karen F. Kuhns, M.D.                                                                                 Internal Medicine
285 SE 5th Avenue Phone: 561-272-8991
Delray Beach, FL 33483 Fax:561-272-8985

                                    Authorization to release Healthcare Information


Patient’s Name:________________________________ Date of Birth:_____________

Previous Names:__________________________ Social Security#:____________



I request and authorize Dr. Karen Kuhns to release my healthcare information to the party specified below:

Name:________________________________ Phone:__________________________

Secure Fax:_____________________



I have specified the healthcare information/treatment that I would like to be sent below:



□ Yes □ No     I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person listed above. I understand that the person listed

                         above will be notified that I must give specific written permission before disclosure of these test results to anyone.

□ Yes □ No     I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person listed above.
 

□ Yes □ No     Healthcare information relating only to the following treatment or condition:______________________________________________________


By my signature below, I state that I understand I will be responsible for any copying or production charges associated with these records. These charges include a charge of $1 per page up to 25 pages, and 25 cents for any page over 25 pages. If the chart I am requesting records from is in a storage location, I will be charged a $25 retrieval fee to get the chart from storage.



Patient Signature:_________________________________________________________________ Date:________________

This authorization will expire ninety days after it is signed.