Records Release Form

I give permission to fax my medical records to the above listed person, company, or medical facility. I understand that my records will be sent via phone line.

It is my understanding that by signing this authorization for release of my records, I am giving permission for H & D Cardiology, PA, to receive copies of any medical, psychiatric, AIDS, Aids Related Syndromes, HIV Testing, Alcohol and/or drug abuse related information for the above listed person(s) or organization. I also understand that this authorization may be revoked at any time except to the extent action has been taken prior to revocation. This consent is valid indefinitely until there is written communication received to revoke.