Age 18 and Up Release of Information Form

PATIENT NAME:

PATIENT DATE OF BIRTH:

PATIENT EMAIL FOR PORTAL:

Patient email required for portal access as of age 18

PATIENT PHONE NUMBER:

PREFERRED METHOD OF CONTACT FOR NOTIFICATIONS You may opt out of notifications at any time by contacting the practice at 309-662-0504, opt 3

PHONE CALL TEXT EMAIL

By signing below, I hereby authorize Bloomington Pediatrics, LTD to release any and all of my protected health information to the following persons:

NAME:

RELATIONSHIP:

PHONE NUMBER:

AUTHORIZED FOR PORTAL ACCESS?

YES NO

IF YES, ENTER EMAIL ADDRESS:

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This consent will expire on the date entered or upon written notice from the patient.

Enter Consent Expiration Date

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.

Signature of patient:

Date:

Please upload a photo of your Driver's License or Government ID for identity verification.

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Please upload a file

Your information will be encrypted.