I hereby authorize the release of the following records:
TO: Caring Hands Children’s Clinic, LLC
P. O. Box 1400
Monticello, MS 39654
601-587-4515 (fax)
I understand that:
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
If you are NOT the patient but are signing on behalf of the patient, please complete below:
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.