I do hereby consent and authorize the specified facility to release my medical records. I understand that this authorization is valid for a period of one year after date of signature and may be revoked at any
time prior to release of information. The facility, employees, attending physicians, Physician's Assistant, and Family Nurse Practitioner s are released from legal responsibility or liability for the release of the above information to the extent indicated and authorized herein. I understand that the information to be released is protected under state and federal laws and cannot be re-disclosed without my further written consent unless other reasons provided for and by state or federal law.
I agree that a copy of this release or a fax of this release shall be valid as the original release. I understand that I am entitled to a copy of this authorization. I understand that I have a right to refuse to sign. Also, I understand that East Coast On-Site Medical Care, Inc. will not condition treatment in whether or not I provide authorization for the request use or disclose.
