Authorization to Release Healthcare Information

Patient’s Name:

Date of Birth:

I request and authorize

to release healthcare information of the patient named above to:

Name:

Address:

City:

State:

Zip Code:

This request and authorization applies to:

All healthcare information

Healthcare information relating to the following treatment, condition, or dates:

Please Specify:

Other:

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.

Patient Signature:

Date Signed:

There is a fee to transfer medical records please ask office employee for details.
THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.

Your information will be encrypted.