Medical Records Release Form

Please correct the errors described below.

Please release my protected health information to the following person(s):

By signing this form, I authorize the release of my protected health information as stated above. This authorization is valid for 1 (one) year.

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.

Your information will be encrypted.