Release of Information

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

Patient's name:

Doctor's Name:

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.

Parent or Patient Signature:

Patient Name:

DOB:

Provider Name:

Specialty:

Address:

Phone:

Fax:

Email address

Add New Provider

Your information will be encrypted.