I hereby authorize My Personal Physician to disclose my Protected Health Information (PHI) as contained in the records maintained by My Personal Physician, including, but not limited to highly confidential information concerning communicable diseases, HIV, AIDS, psychiatric, chemical or alcohol dependency, laboratory test results, or any other medical treatment. This authorization does not include psychotherapy notes.
Patient, the patient's representative, or patient's guardian (if the patient is a minor or incapacitated adult)