Release of Information Policy

I hereby authorize Dr. William S. Gilmer to release or obtain any and all medical information required in the course of my care. This disclosure may include HIV test results, psychiatric or psychological records or any other information relating to the diagnosis, treatment or therapy of my disease, illness or condition.

I assign Dr. Gilmer all payments for medical services rendered to myself or my dependent. I understand that I am responsible for any amounts not covered by insurance. I release Dr. Gilmer, his employees and agents from liability for following this authorization request.

I have received a copy of this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. Our Notice of Privacy Practices is also accessible on our website.