Thomas Carmen MD and Associate, Village at Pine, 1500 Village Run Road Suite 308, Wexford, PA 15090, Telephone: 724-934-1900, Fax: 724-934-3388

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I authorize Thomas Carmen, MD and Associates to release my medical records to:

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The following information is to be released:

All medical records including any alleged or actual drug/alcohol abuse, sexually transmitted disease including any HIV/AIDS-related information, mental health, psychiatric, and / or psychotherapy treatment records. If any of this information is documented in my medical file, I agree to release it.

All medical records with the exception of:

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Sexually transmitted disease including any HIV/AIDS information

Mental Health, psychiatric and/or psychotherapy information

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Authorization For Release of Medical Information

I authorize Thomas Carmen, MD and Associates to release my medical records to: