Authorization For Release of Medical Information
I hereby authorize Enfield Adult Education to furnish medical information concerning
_____________________________ to ___________________________ ( Clinical Facility ). Any and all information may be released , including but not limited to :
- drug and / or alcohol abuse records and / or HIV test results ( if any ), with exception to anything specifically noted below :
The information may only be used for the following purposes : screening for affiliation with the clinical facility in order to perform clinical training .
This authorization is effective now upon date of signature below , and will remain in effect for one year from this date . I understand that I have the right to receive a copy of this authorization .
Signature ________________________________________________ Date ______________
Printed Name _______________________________________________________________
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