to release healthcare information of the patient named above to:
This request and authorization applies to:
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.
There is a fee to transfer medical records please ask office employee for details.
THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.
Your message will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2020 Hush Communications Canada Inc.