Authority to Release Information

Please correct the errors described below.

I authorize (kindly indicate name of doctor(s) below) to release medical information from my medical records and sent it to:

I authorize you to release my entire record to the physician named above subject to the following limitations:

This authorization will automatically expire one year from the date signed. I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance thereon.

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.