Authorization to Release Healthcare Information

Please correct the errors described below.

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.