Age 18 and Up Release of Information Form

Please correct the errors described below.
Patient email required for portal access as of age 18

I give permission for Bloomington Pediatrics, LTD to release information to the following persons:

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

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.