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PO BOX 5848 CAREFREE, AZ 85377 P: (480) 595-0431 F: (480) 595-2322 www.carefreeinternalmedicine.com
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to release all information included in my medical records to Carefree Internal Medicine. This includes all notes, labs, imaging, tests, and notes from other specialists. This also includes communicable and Sexually Transmitted Disease (STD) results (HIV, Syphilis, Hepatitis, Chlamydia, and Gonorrhea).
Patient's Name
Patient's Social Security Number
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Date of Request
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