AUTHORIZATION FOR RELEASE OF INFORMATION

I Hereby Authorize:             HealthSouth City View                       (Name of Facility)

                                                 6701 Oakmont Blvd.                               (Street Address)

                                                 Fort Worth, TX. 76132                            (City, State, Zip)

                                                 PH.  (817) 370-4740

                                                 Fax. (817) 370-4974

to release to:          ________________________________________ (Specific Person)

                                 ________________________________________ (Name of Facility)

                                 ________________________________________ (Street Address)

                                 ________________________________________ (City, State, Zip)

the following information from the medical records on:

                              ________________________________________ (Name of Patient)

                                 ________________________________________ (Date of Birth)

Information To Be Released:

            ____ Discharge Summary                                     ____ Lab Reports

               ____ Psychiatric History                                       ____ Medication Records

               ____ History Physical                                           ____ Integrated Progress Notes

               ____ Psychological Testing                                  ____ Consultation Reports

                ____ Psychosocial Assessment                             ____ Radiology Reports

                ____ Physician Progress Notes                             ____ EKG,EEG,EMG, Reports

                ____ Treatment Plan                                             ____ Operative Reports

                ____ Psychiatric Evaluation & Admission Note  ____ Pathology Reports

The information specified above is to be released for the following purpose and that purpose only. Any other use is forbidden:

PURPOSE:

I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it and that this authorization will automatically expire 180 days from the date of my signature. Also, I understand that a photocopy of this authorization is valid for release of my records.

I understand that the specific type of information to be disclosed may include a history of the diagnosis and/or treatment of mental conditions, chemical or alcohol abuse and dependency, H.I.V. , and A.I.D.S. , and I have given my specific consent for disclosure of this information as indicated below.

Federal law (42CFR, Part2) prohibits redisclosure of this information by the recipient. Medical records photocopies are subject to a prepaid fee.

______________________________________                 ________________________

Signature of Patient                                                           Date Signed

(Required for Minors 16 and Older)

___________________________________

Signature of Parent/Guardian    (Required for patients under 16)