Records Release Authority Form

Please correct the errors described below.

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).

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.

Your information will be encrypted.