Medical information is generally not released to others without your consent. Do not sign this release form unless it is filled out completely and you believe that the release of this information is in your best interest.

Information may include, but is not limited to: professional opinions, reports or examinations, tests, treatment, diagnosis, and prognosis.

I understand that I may revoke my authorization at any time by providing a written request for such, except as to actions that may have been taken in reliance upon it. I understand this form may serve as my consent for communication between my counselor and my medical provider at Buffington Family Medicine. I understand that a photocopy of this authorization may serve as an original.