Records Release Authority Form

I, (Please state name below) hereby authorize Eric A. Arp, DPM to release a report of my treatment and/or x-rays, as well as other data pertinent to the treatment of me from (State date below) to (State date below).

Name:

From:

To:

Reason for Records Request:

I understand that x-rays are property of this office and agree to return them within 60 days.

DISCLAIMER: 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.

Date:

Signature of Patient, Parent, Guardian, Or Legal Representative:

Patient’s Date of Birth:

Address:

City:

State:

Zip:

Witness Name Printed:

Your information will be encrypted.