Release of Information

Michael D. McGee, M.D.

Tel: 978 360 6071

Board Certified, General Adult Psychiatry, Addiction Psychiatry and Psychosomatic Medicine

Fax: 877 399 5883

6613 B Bay Laurel Place, PO Box 2589, Avila Beach, CA 93424


Authorization to Release Medical Records and Verbally Share Protected Health Information


Patient Name:


Street Address:

Phone #:

City, State, Zip Code:


I authorize Dr. McGee to release all of my Protected Health Information (PHI—to include HIV/AIDS results and drug or alcohol abuse information protected by Federal Regulation 42CFR) and to discuss my treatment with the following provider:



Provider/ Other Role:

Phone #:

Fax #:

Street Address:

City, State, Zip Code:


I understand that consent is subject to revocation at any time in writing to Dr. McGee, except if medical records or verbal information have already been disclosed. I understand that if health information is disclosed by this authorization, it may no longer be protected under the terms of the privacy rules and the recipient may be able to legally re-disclose the health information to others. I have carefully read and understand the above statements. I hereby release Dr. McGee from all legal responsibility or liability from the disclosure of PHI either in my medical records or verbally. I wish for this authorization to remain in place for the duration of my treatment and beyond until such time as I have revoked this authorization in writing to Dr. McGee.




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General Adult Psychiatry, Michael D. McGee
Signature Certificate
Document name: Release of Information
Unique Document ID: 976a4724e01d4cc6da7e6a7170958a6cc04ed30b
Timestamp Audit
February 15, 2016 2:41 pm ESTRelease of Information Uploaded by Linda Callahan - IP