I understand that this will include all doctor's notes, labs results, studies and other medical correspondence. It may contain psychiatric and substance abuse treatment and information pertaining to HIV status.
The information is to be disclosed to:
Maria Gonzalez Berlari, MD
5251 W Campbell Ave Ste 105
Phoenix, AZ. 85031
The supplied information will be used for continuation of my medical care at this office. I understand that this consent may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization, Unless otherwise, this authorization will expire one year from the date of signing.