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MEDICAL INFORMATION RELEASE FORM

I,

The patient/guardian/heathcare power of attorney, authorize

Quick Claimers to:

Receive medical and other information from:

Release medical and other information to:

TREATMENT DATES TO BE DISCLOSED:

PURPOSE OF THE DISCLOSURE:

SPECIFIC DESCRIPTION OF THE INFORMATION TO BE DISCLOSED:

I understand that the purpose of this authorization is for the use and/or disclosure of my protected health information (PHI) and that it may contain information that is protected under state laws and federal regulations. I understand that when the above information is disclosed it may be subject to re-disclosure and will no longer be protected by Privacy Protection Rules. I understand that I have the right to revoke this authorization at any time and that my revocation must be submitted to Quick Claimers. I understand that my revocation is not effective to the extent that the persons or organizations in which I have authorized to use and/or disclose my protected health information have acted in reliance upon this authorization. I understand that I may refuse to sign this authorization and my refusal to sign will not affect my ability to receive treatment, payment enrollment, or eligibility for benefits. I understand that I will be given a copy of this authorization upon my signature.

I hereby authorize Quick Claimers to disclose/release medical records and other information obtained in the course of my diagnosis and/or treatment. I agree to pay copy charges if applicable.

I hereby release Quick Claimers from any liability which may result from this disclosure of confidential medical information or which may arise or the result of the use of the information contained in the information released. Unless withdrawn, this consent will expire 90 days from the date signed.

This information may include Medical/Surgical, Psychiatric, Substance Abuse and HIV/AIDS information.