By checking, I authorize the transfer of medical records for my child to Rainbow Valley Pediatrics:

 605 Welch Street

Silverton, Oregon 97381

503-782-1975 (office Phone)

503-343-6232 (fax)

I consent to the release of information related to HIV/AIDS or infection with any other communicable diseases and information related to behavioral or mental health services and treatment for alcohol and drug abuse, with the rest of the medical records.

Treatment/Continuing medical care

I understand that I may revoke this authorization in writing at any time. Otherwise, this authorization shall remain valid until such time as it is revoked in writing.