Release of Medical Information Notes

Patient full name: Johnathan Smith Date of birth: 15 March 1980 Medical record number or ID: 123456789 Authorized releasing party – name: Dr. Emily Johnson Authorized releasing party – address/contact: 123 Health St, Springfield, SP1 2AB, Phone: 01234 567890 Recipient – name: Sarah Smith Recipient – relationship to patient: Spouse Recipient – address/contact: 456 Elm St, Springfield, SP3 4CD, Phone: 09876 543210 Description of information to be disclosed: The patient has authorized the release of all medical records pertaining to mental health treatment, excluding any records related to drug and alcohol treatment. No HIV/AIDS information is to be disclosed. Format of disclosure: Electronically via secure portal Purpose of disclosure: The disclosure is for care coordination purposes as requested by the patient. Expiration of authorization: This authorization will expire on 1 November 2025. Revocation and rights statement: The patient has the right to revoke this authorization in writing at any time, except to the extent that action has already been taken based on this authorization. Redisclosure limitations and legal protections: The information disclosed may not be redisclosed without the patient's consent, in accordance with state and federal laws protecting patient privacy. Signature of patient: Johnathan Smith Date of signature: 1 November 2024 Printed name of patient: Johnathan Smith Interpreter name (if applicable): Maria Gonzalez Interpreter signature (if applicable): Maria Gonzalez