Gerald = W

Gerald W. Luckey, = MD

Victor J. Thoendel, = MD

Matthew P. Summers, = MD

Butler=20 County=20 Clinic, P.C.

336 South=20 9^th Street David City, NE = 68632=20

Phone: 402-367-3193 * Fax: = 402-367-3261

A=20 Professional Corporation

=20 Mark V. Carlson, MD

=20 Lawrence Rudolph, MD

Leah J.=20 Hays, PA-C =20

RELEASE OF MEDICAL=20 RECORDS

Name:

Date of=20 Birth:

Address:

Social Security=20 #:

Phone:

Requester:

Name:

Where do you = want your=20

Address:

information=20 sent

Provider:

Name:

Who is = releasing=20 your

Address:

information

Information Requested:

□ = Complete=20 Record

□ = Specific Progress Note=20 (please list date = needed)______________________

□ Lab, = Data,=20 Date

□ = Other______________________=20 (please be specific)

□ EKG, = Date=20

□ =

□ = History &=20 Physical

Purpose of Release:

&n= bsp; &nb= sp; =20 □ Transferring Medical = Care

□=20 Moving

&n= bsp; &nb= sp; =20 □ Insurance Coverage

□ = Other

READ CAREFULLY: I=20 understand that my medical records are confidential. I understand that by = signing this=20 authorization I am allowing the release of my medical information=20 requested to the agency or person specified above. Drug and alcohol abuse = information=20 records are specifically protected by federal regulations and by = signing=20 this authorization, I am allowing the release of any drug, alcohol = and/or=20 psychiatric information records to the agency or person =20 specified above. =20 I understand that my records may contain information = regarding the=20 diagnosis and treatment of HIV (AIDS virus) and other sexually = transmitted=20 diseases and by signing this authorization, I am allowing this = information=20 to be released to the agency or person specified above. I also understand that I = may=20 revoke this authorization at any time by written request from = myself or my=20 family except to the extent that action has already been taken in = reliance=20 upon it. =20

This consent = shall remain=20 in effect for six (6) months from the date executed unless revoked = earlier=20 by me. If revoked = earlier, it=20 is understood by all parties that the information release prior to = being=20 notified or such revocation was made at my request with my = consent.=20

I have read = the above=20 foregoing Authorization for Release of Information and do hereby=20 acknowledge that I am familiar with and fully understand the terms = and=20 conditions of this consent.

Date:

Signature:

If = signed by=20 personal representative, state relationship/authority to do=20 so

Date: &n= bsp; &nb= sp; &nbs= p; =20 Signature:

THE FOLLOWING = APPLIES ONLY=20 TO DRUG/ALCOHOL ABUSE OR TREATMENT INFO. = RECORDS:

Prohibition on = disclosure:=20 This information has been disclosed to you from records whose=20 confidentiality is protected by federal law. Federal regulation = 42-CFR-2=20 prohibits you from making further disclosure of it without the = specific=20 written consent of the person to who it pertains, or as otherwise=20 permitted by such regulations. =20 A general authorization for the release of medical or other = information is NOT sufficient for this purpose.