Authorization of Release of Records to Third Party

(patient name)

, hereby authorize New Orleans Podiatry Associates and its affiliated agents to release my medical records, or the medical records of my minor child

(name of minor)

or a person for whom I have power of attorney

(name of person)

in their entirety to

(name of third party recipient of medical records)

This includes but is not limited to physician progress notes, operative reports, radiology reports, laboratory results, and any external or internal information that has been created or collected on my behalf

Third Party Contact:

Street:

City:

State:

ZIP:

Tel:

Email:

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/Guardian

Date

Signature of Physician

who has verified release of records and power of attorney when applicable

Date

New Orleans Podiatry Associates

2626 Jena Street, New Orleans, LA 70115 - t. 504.897.3627 f. 504.897.3339
3939 Houma Blvd, Bldg. 5, Ste. 217, Metairie, LA 70006 - t. 504.457.2300 f. 504.897.3339nolapodiatry.com | nolapodiatry@gmail.com

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