Anna M. Cabeca, D.O., P.C., FACOG, Board Certified Obstetrics & Gynecology

“Striving for Excellence in Women’s Health”

Office: 2712 Parkwood Drive Mailing: P.O. Box 920

Brunswick, GA 31520 Brunswick, Georgia 31521

Phone (912) 267-7780

Fax: (912) 267-6293

I, ______, authorize and request Anna Cabeca, D.O. to obtain from/release to:

(Name and Address of Person or Organization to Receive or Provide Information) the following type(s) of information from my records (and any specific portion thereof):______

______

______Date of birth______

(Patient)

Records From: ______to ______

Reason for Disclosure: ______

I am aware that some of the health care information or other information contained in the requested or released medical records may be confidential or privileged and I hereby specifically waive any privilege or confidentiality existing under federal or state law regarding such information including, but not limited to protection afforded to:

(1)  AIDS Confidential Information (O.C.G.A. 31-22-9.1 and 24-9-47)

(2)  Medical Information Concerning Alcohol and Drug Abuse (42 C.F.R part 2)

(3)  Medical Information concerning Drug Dependence (O.C.G.A. 26-5-17)

(4)  Medical Information Concerning Alcohol and Drug Dependency (O.C.G.A. 37-7-166);

(5)  Medical Information Regarding Mental Illness (O.C.G.A. 37-3-166);

(6)  Communication Made to Psychiatrist (O.C.G.A. 24-9-21)

(7)  Communication Made to Licensed Applied Psychologist (O.C.G.A. 43-36-16)

(8)  Medical Information Concerning Mental Retardation (O.C.G.A. 37-4-125)

(9)  Communications Made to Licensed Clinical Social Worker, Clinical Nurse in Psychiatric/Mental Health, Licensed Marriage and Family Therapist, or Licensed Professional Counselor (O.C.G.A. 24-9-21).

This authorization and consent is subject to revocation at any time, except to the extent that Anna Cabeca, D.O. has already taken action in reliance on it. If not previously revoked, this authorization will terminate 90 days from the date appearing below.

“Information released with my written consent shall be held strictly confidential by the recipient and may not be released to any other party without my written consent unless disclosure is required by law.”

Date: ______Signature: ______

(Patient or authorized Person)

Witness: ______Title: ______

NOTE OF RECIPIENT:

THE INFORMATION THAT HAS BEEN DISCLOSED TO YOU IS OR MAY BE PROTECTED BY STATE AND FEDERAL LAW. YOU ARE PROHIBITED FROM MAKING FURTHER DISCLOSURE OF THIS INFORMATION UNLESS FURTHER AUTHORIZATION IS OBTAINED OR DISCLOSURE IS OTHERWISE PERMITTED BY LAW. A GENERAL AUTHORIZATION FOR RELEASE OF INFORMATION MAY NOT BE SUFFICIENT.

The information requested was release to: ______on ______

By: ______

Revised 1-1.13