(The psychiatric practice of H. Berryman Edwards, MD is closed.)

PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

H. Berryman Edwards, M.D.

4039 170th Ave. SE

Bellevue, WA 98008

Fax: 877.226.2657

I keep a record of the health care services we provide you. You may ask me to provide a copy of that record via fax or digital media. You may also ask me to correct that record. I will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels me to do so. You may request a copy of your record by mail/fax at the address/number above. I do not provide printed copies. Statutory charges apply at my discretion.

I, _______________________________________________ hereby authorize Dr. H. Berryman Edwards to release information in my medical records, including (initial all that apply):

_________Entire record

_________Diagnoses

_________Treatment information

_________Other (specify): __________________________________________________

I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment of HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use. If I have been tested, diagnosed, or treated for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use, Dr. Edwards is specifically authorized to release all health care information relating to such diagnosis, testing, or treatment.

I understand authorizing Dr. Edwards to release my medical record to a third-party may result in a waiver of my privilege rights or denial of medical, life, or disability insurance and that consultation with an attorney may be advisable.

The information specified may only be released to (include fax number):

I also authorize Dr. Edwards to discuss my treatment if appropriate. This release information may be used solely for medical treatment, insurance claim, or legal purposes. It may be revoked at any time by written request.

Signed: _____________________________________________________ Date:_____________