Date Patient Name Date of Birth Address I hereby authorize: Marjaneh Rouhani, MD204 S. Beverly Dr. Suite 111, Beverly Hills 90212 To release to: Name of Person or Agency Address Information to be disclosed: All medical information Specific medical information Please describe: Purpose and need for such disclosure: I hereby consent to the release of any medical information, which may include the following: psychiatric, alcohol and/or drug abuse records, AIDS, AID-related complex (ARC) and HIV infection. I understand that this authorization may be withdrawn by me at any time. Revocation of this authorization will not affect any information already released. Patient Signature Date Witness Date
