Authorization to Dr. Sterling to Release Medical Information to Others
A FEE MAY BE CHARGED FOR TIME SPENT TO PREPARE AND RELEASE INFORMATION
-- Please Print This Document, Fill it Out, and Send the Original to Dr. Sterling by Regular Mail --
(To print a document that is in a frame, just click your mouse inside the frame, then print.)

I, (print your full name)_______________________________________________________ , hereby authorize Ron Sterling, M.D., to release information in my medical records. Only the following information may be released (please initial all that items you wish released):

  1. _____ Diagnosis.

  2. _____ Treatment information.

  3. _____ Medication information.

  4. _____ Summary of diagnosis, treatment and prognosis.

  5. _____ Photocopies of all medical records (Fee charged).

  6. _____ Other (please specify below).

    ___________________________________________________________

I understand that my express, written consent is required to release any health care information relating to testing, diagnosis, and/or treatment of HIV (AIDS), sexually transmitted diseases, psychiatric disorders or mental health problems, and drug, alcohol or other substance use or abuse. If I have been tested, diagnosed, and/or treated for HIV (AIDS), sexually transmitted diseases, psychiatric or mental health disorders, drug, alcohol or other substance abuse, I specifically authorize Ron Sterling, M.D., to release the following health care information relating to such diagnoses, testing or treatments (indicate which ones by initialing the appropriate items): _______ Information relating to treatment of HIV (AIDS) and sexually transmitted diseases; _______ Information relating to psychiatric disorders or mental health problems; _______ Information relating to drug, alcohol or other substance abuse.

I authorize Dr. Sterling to provide such information in the following manner(s) to the persons and/or organizations specified further below (please initial all forms of communication allowed):

  1. _____ By regular mail.

  2. _____ By telephone.

  3. _____ By Internet chat.

  4. _____ By e-mail.

  5. _____ By Fedex or courier. (Fee charged.)

  6. _____ By registered/certified mail, return receipt requested. (Fee charged.)

The information specified may only be released to the following person(s) and/or organization(s). Please print clearly the full name, full address, telephone number and e-mail address (if relevant) of said person(s) and/or organization(s).

___________________________________________________________
(Person to whom information is to be released)

___________________________________________________________
(Organization to whom information is to be released)

___________________________________________________________
(Address of Person or Organization)

___________________________________________________________
(Telephone Number of Person to whom information is to be released)

___________________________________________________________
(E-mail Address of person to whom information is to be released)

This released information may be used solely for health care treatment, insurance claim, or legal purposes. This authorization expires in 120 calendar days from the date on which the client signed it. It may be revoked at any time by written, signed, and delivered request.

___________________________________________________________
(Signature of client)

___________________________________________________________
(Social Security Number of client)

___________________________________________________________
(Date signed)

THIS FORM MUST BE SIGNED BY A WITNESS

___________________________________________________________
(Print name of Witness to client signature)

___________________________________________________________
(Relationship of Witness to client -- friend, sister, spouse, doctor, etc.)

___________________________________________________________
(Date signed)

___________________________________________________________
(Telephone Number or Address of Witness)

___________________________________________________________
(Signature of Witness)

RON STERLING, M.D.
12356 Northup Way, #100
Bellevue, WA 98005
Phone: 206-784-7842