Confidential Health Information Enclosed

Authorization for Release of Medical Information

Patient's Name

Date of Birth

Address

City

State

Zip

Patient's phone number

Date of Request

Date needed

I authorize Abundant Health Family Medicine to release information to:

I authorize Abundant Health Family Medicine to obtain information from:

Add new row

Purpose for this request: (check one)

Transfer of care Upcoming appointment Insurance verification Other

If other, specify

Type of records requested: (check one)

Imaging reports Recent visit notes Laboratory results Other

If other, specify

I understand that
My right to healthcare treatment is not conditioned on this authorization. I may cancel this authorization at any time by submitting a written request to the office. This request will be valid for one year from the date signed. There may be a charge for the requested records.

Signature of Patient/Parent/Guardian

Date

Your information will be encrypted.