Consent for Release of Confidential Information Name of Patient * First Name Last Name Patient Date of Birth * MM DD YYYY I hereby authorize the release of information regarding my treatment: FROM: Jason Wuttke, MD 2633 Napoleon Avenue, Suite 805 New Orleans, LA 70115 Phone 504-301-9884 • Fax 504-655-9776 TO: Recipient Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Fax (###) ### #### For the Purpose Of: (Check all that apply) Continued treatment Continuation of care Transfer of care Medical/Legal reasons Disability evaluation Payment/Insurance reasons Other If 'Other' please specify: Information to be Provided: (Check all that apply) Initial evaluation Last 2 visits Medication records Labs Diagnosis only Entire record Acknowledge attendance only Letter Other If 'Other' please specifiy: PLEASE READ THE FOLLOWING AND SIGN BELOW INDICATING YOUR UNDERSTANDING AND AGREEMENT. Patient or Parent/Guardian First Name Last Name Date of Patient/Parent signature MM DD YYYY Witness First Name Last Name Date of Witness signature MM DD YYYY I hereby authorize the release of information regarding my treatment, and I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. TO THE PARTY RECEIVING THIS INFORMATION: This information has been disclosed from records whose confidentiality is protected by federal law. Federal Regulation (42 CFR Part 2) prohibits you from making any further disclosure without specific written consent of the patient, parent, or legal guardian. A general release of medical information is NOT sufficient for this purpose. Thank you!
