Authorization for Release of Information

Please correct the errors described below.

Patient Name:

Date of Birth:

I, the undersigned, hereby authorize the release of information:

TO:
Medical Center Pediatrics 30400 Telegraph Rd. Ste 101 Bingham Farms, MI 48025
Telephone: (248) 642-5437
Fax: (248) 642-5456

Medical Center Pediatrics 5793 W. Maple Rd. Ste 153 West Bloomfield, MI 48322
Telephone: (248) 539-7726
Fax: (248) 539-7823

FROM:

Doctor/Clinic/Hospital:

Address

Phone Number:

Fax Number:

Please release the following information:

All health information (including growth charts and vaccination records)

History/Physical Exam

Progress Notes

Discharge Summary

Consultation Reports

Diagnostic Test Reports

Radiology/Images

Lab Results

Pathology Reports

Other

If Other is selected, please specify:

Purpose of disclosure:

Treatment/continuing medical care

I understand that I may revoke this authorization in writing at any time. Otherwise, this authorization shall remain valid.

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. Formatted text

Signature

Relation to Patient

Date

Your information will be encrypted.

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide