Release of Information

Wellcare Physicians Group, LLC

100 Morse St. # 105, Norwood, MA 02062

phone (781) 769-8700 fax (781) 769-8704

wellcarepg,com

RELEASE OF INFORMATION

Patient Name: DOB

I authorize RELEASE of patient information from Wellcare Physicians Group to:

_____________________________________________________________

_____________________________________________________________

I authorize Wellcare Physicians Group to REQUEST patient information from:

_____________________________________________________________

_____________________________________________________________

Please include:

__ Complete medical records (includes mental health records/records related to alcohol or drug abuse)

__ Physical exam/ Labs

__ Discharge summary

__ Other

Purpose: ___ Treatment ___ Financial ___ Legal ___ Other

I understand that:

1. I may withdraw authorization at any time by submitting a written request to this practice. Authorization may be withdrawn except to the extent that action has already been taken in reliance on this authorization. If the authorization was obtained as a condition of obtaining insurance coverage, other laws provide the insurer with the right to contest a claim under the policy, even if authorization has been withdrawn.

2. I may refuse to sign this authorization.. If I refuse to sign, my treatment, payment, health plan enrollment, or eligibility for benefits will not be affected

3. This release will expire one year from the date of signature unless otherwise specified.

4. To the extent that my medical record contains information regarding alcohol or drug treatment that is protected by federal law, I authorize disclosure of such information

5. Once Wellcare Physicians Group has disclosed my health information to the recipient I authorize, we cannot guarantee that the recipient will not redisclose the information to a third party.

____________________________ ________________ __________

Signature of Patient or Guardian Relationship to Patient (if Guardian) Date