Release of Medical Records

Please correct the errors described below.

Authorization to Release Protected Health Information

This request will be honored within 7-10 business days. There may be a fee depending on the size of your medical records. Prepayment is required before your medical records will be sent.

I authorize Allergy Institute, P.C. to release medical information from my medical record and send it to:

This authorization will automatically expire one year from the date signed. I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance thereon.

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.

Loading...