I hereby authorize PORTER MEDICAL ASSOCIATES, INC to release photocopies of my medical records and/or health information as follows:

_____ To the following named individual or organization

OR

_____ Into my own keeping.

I agree to pay $1.00 for the first copy and 0.50 cents per page for each additional copy or copies before such are released and will also pay the actual cost of postage if the record(s) is(are) to be mailed. I further release PORTER MEDICAL ASSOCIATES, INC from the responsibility for any deleterious effect the release of my clinical medical records may have upon myself or others both now and in the future. I personally accept all responsibility for my own distribution and interpretation of medical information contained therein and hold blameless PORTER MEDICAL ASSOCIATES, INC for conclusions or opinions drawn from said records without professional knowledge, assistance or review.

____________________________________________________________

BY STATE LAW, you must be advised that: The information authorized for release may include records which may indicate the presence of a communicable or venereal diseases which may include, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea, and the human immunodeficiency virus also known as Acquired Immune Deficiency Syndrome (AIDS).

______________________________________________________________

I realize that by the release and/or receipt of these records that I am accepting responsibility for the protection of my own right of medical record confidentiality.

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