I ________________________________, do hereby grant authorization to release information on my behalf regarding my treatment and condition to the following:

m Name _______________________________ Spouse / Others

m Name ________________________ Children / Parent / Guardian

m Telephone answering machine or voice mail at ________________

m To me at these number(s) _(w)_____________(h)_____________

My address is correctly stated in my chart and Montgomery Family Medicine may mail information there.

It is my responsibility to make Montgomery Family Medicine aware of any changes to this authorization.  This authorization is in effect until rescinded by me.


Patient Signature___________________________ Date___________