Release of Information Authorization Form

Acknowledgment of Receipt of Notice of Privacy Practices

This signed form acknowledges that you have received a copy of our practice’s Notice of Privacy Practices as required by Federal Law. By signing below you are acknowledging that you understand and have read this notice. This notice is yours to keep.

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

Please Print Patient Name

Patient Date of Birth

Signature of Patient/ Guarantor/ Legal Guardian

Date

With whom may we discuss patient's information? (For patients over age 18)

Patient Only

Add Another Person

Your information will be encrypted.