McKenzie Medical Center's
Authorization to Release Medical Information

Please print off the form, fill it out (all sections MUST be completed) and then you can email a copy to This e-mail address is being protected from spambots. You need JavaScript enabled to view it , fax a copy to 731-352-4459 or mail a copy to 205 Hospital Drive, Suite A, McKenzie, TN 38201 Attn: Medical Records.

I hereby authorize (provider name and location) ____________________________________________________________________________________ and its physicians, employees and agents to release or disclose the below-named recipient of all my medical records including any specially protected records such as those relating to psychological or psychiatric impairments, drug abuse, alcoholism, sickle cell anemia, sexually transmitted disease, or HIV/AIDS infection.

Patient Name: _______________________________________________________________________________________________________________________________________________________________

Date of Birth: ____________________________________________________________________

Social Security Number: _________________________________________________________________

I hereby authorize the release of medical records to (provider name and location): ____________________________________________________________________________________________

Purpose of disclosure: _____________________________________________________________________________________________________________________________________________________

This authorization will expire on: __________________________________________________ Date or event may not exceed one year

This request and authorization applies to: (Please mark only ONE choice below)

_______   All medical records    OR

_______   Healthcare information relating to a specific treatment, condition or specific dates of services, specific records to be released (e.g. Labs, imaging reports, etc) - Please note specific information below:



If you DO NOT WANT certain portions of your medical records release, please initial the box for the information you do not want to be released:

____  Substance Abuse            ______ Psychological or Psychiatric Treatment           _____ HIV/AIDS/STD


I understand I have the right to revoke this authorization by written notification to the Privacy Officer, except to the extent it has acted in reliance theron before notice of revocation. I understand that any disclosure of information carries with it the potential for an unauthorizd re-disclosure which may not be protected by federal confidentiality rules. I understand that I may request a copy of this authorization. I understand that I can refuse to sign this authorization and that the above-named office may not condition treatment on my signing of this authorization.

(Signature of Patient or Legal Guardian)

(Relationship to Patient)

______________________________________           ________________
(Patient's Name)                                              (Date)

_____________________________________              _______________
(Printed Name of Patient or Legal Guardian)      (Date)


_____________________________________________________________________________ Witness (Signature of MMC Associate)



McKenzie Medical Center
205 Hospital Drive, Suite A
McKenzie, TN 38201
Phone: 731-352-7907 Fax: 731-352-4459



A Patient at Gleason Clinic stated "This is such an easy place to come to, I enjoy coming here and I don't dread coming to see the doctor"