MODEL PATIENT NONDISCLOSURE FORM

1601 N. Tucson Blvd. Suite 9
Tucson, AZ 85716-3450
Phone: (800) 635-1196
Hotline: (800) 419-4777

Association of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto

Print this page, sign and give to your doctor, dentist, therapist, chiropractor and all others who keep your medical files.

Patient Request for Non-Disclosure of Medical Records

I, ___________________________, hereby assert my constitutional right to privacy and expressly forbid my physician, and anyone acting under his or her control, from releasing any of my medical records to a third party without my express consent.

In particular, I decline to consent to the release of my medical records for the purpose of entry into a computer database which may be accessed by third parties outside of the offices or hospitals utilized by my physician.

__________________________________________________ Signature __________Date

__________________________________________________ Address

____________________________City ____________ State ____________________Zip