Age 21 and Over Release of Information Form

PATIENT NAME:

PATIENT DATE OF BIRTH:

PATIENT EMAIL FOR PORTAL:

Patient email required for portal access as of age 18

I (insert name below) give permission for Bloomington Pediatrics, LTD to release information to the following persons:

NAME:

RELATIONSHIP:

PHONE NUMBER:

Add more

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.

Signature of patient:

Patient Phone Number:

Date:

Your information will be encrypted.