I, the undersigned patient/guardian, hereby request and authorize:

To release information listed below from the records of:

I understand this authorization includes the release of all medical records (unless otherwise noted) to include HIV records, psychiatric mental illness, drug/alcohol abuse records, venereal disease and any other statutory protected diseases. By signing, I allow information to be transmitted by fax, I understand that this may limit the security or confidentiality of the records. I acknowledge that I have fully read and understand this authorization. I hereby authorize my medical records to be released to Harbison Covenant Healthcare, and I release Harbison Covenant Healthcare and all staff from any all costs of liability of damages resulting indirectly or directly. This authorization will expire when revoked by me in writing, or in one year. I understand that I may revoke this authorization at any time in writing, but that it cannot be retroactively revoked.