Medical Records Release

Authorization Form

I hereby authorize Lindsay Keith, MD PLLC to request and obtain my medical records from the doctors office entered above. I understand that these records may contain sensitive health information including, but not limited to, diagnoses, treatment plans, surgical procedures, and medication details.

I acknowledge that this consent is voluntary and that I have the right to revoke it at any time by providing written notice to Lindsay Keith, MD PLLC. I am aware that until this revocation is processed, my medical records may still be obtained under the authority of this consent.

This consent will remain in effect for a period of one year from the date of signing, unless otherwise revoked by me in writing.

I also acknowledge that the information obtained under this consent may be re-disclosed by Lindsay Keith, MD PLLC and may no longer be protected by federal privacy regulations.