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The Toledo Clinic has changed its masking policy.
For the safety of our patients and staff, masks are recommended but not required.

Please Note: Masking policies may differ slightly from office to office.
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I hereby authorize the below physician from The Toledo Clinic to release my medical records information.

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Records to be released

By signing I understand that the information in my health records may include information relating to sexually transmitted diseases, acquire immune deficiency syndrome (AIDS), or human immune deficiency virus (HIV). It may also include information about behavior or mental health services, and treatment for alcohol and drug abuse.

This consent is valid for 90 days from the date of signature unless revoked by me in writing before release of information as designed above. A copy of this authorization, including the following disclosure statement, will be furnished to whom the information is to be released. This information has been disclosed to you from confidential records from disclosure by state law. You shall make no further disclosure of this information without specific written and informed release of the individual to whom it pertains, or as otherwise permitted by state law.

If you are the legally recognized representative of the patient you must provide supporting documentation.

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