Release of Information

Please correct the errors described below.

I, (Please input Name below), give Dr. (Please input Doctor's Name below)

permission to contact the following provider(s) regrading my child's current medical care or medical history for the purpose of coordination of care.

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.

Add New Provider

Your information will be encrypted.