AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION


PATIENT IDENTIFICATION                                                 

Name:

Date of Birth:

S.S :

Maiden/Other names known by:



PROVIDER
(Who is releasing information)
Name: Kourosh Bagheri, MD/MS,  a Professional Corporation
1194 Pacific Street, Suite 100
San Luis Obispo, CA 93401
Office # 805-781-9111
Fax # 805-788-0764       


RELEASE RECORDS TO:

Name:

Address:

Office #
Fax #

DATES OF TREATMENT         Dates:__________________________________________

Type of information that will be released: recent labs, procedure records, cardiology and radiology reports,
history and physical, recent visit records, problem list, immunization records

I understand that my medical record may also include information on diagnosis/treatment related to psychiatric or
psychological conditions, drug and/or alcohol abuse, acquired immune deficiency syndrome (AIDS), and/or HIV
status.

I understand and agree that the information, if any, pertaining to
any such diagnosis/treatment described above may be released.


PLEASE INITIAL THE STATEMENT THAT APPLIES I do______ do not_____ authorize this information to be
released.
(You must initial one) Limitations, if any:_____________________________________________
____No limitations

Signature of Patient or Legal Representative:______________________________Date ____________

Relationship to Patient:___________________________________________________________