Release of Medical Records

Please correct the errors described below.


I authorize the release of medical records as follows:

(e.g. Office Visit Notes, Allergy Testing, Entire Chart, Etc.)

This authorization expires 30 days from the date of the signature below. I understand that I may revoke this authorization at any time with a written, signed and dated notice. However, disclosures made prior to the revocation will not be affected. A copy of this authorization may be used in place of the original with the same effectiveness. I understand there may be fees associated with making copies and mailing these records.

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.