Release of Information Form

Patient's Information

Name

Date

Email address

By signing this release, I give Dr. Ronit Levy consent to speak with the care provider listed below regarding my case.

Person/Provider Name

Person/Provider Phone Number

Person/Provider E-Mail:

Relationship to Patient

Information To Be Released

Diagnosis

Treatment Process and Progress

All Medical Records

Other

If other, please specify

Patient's Signature

Date

Parent/Guardian Signature

Date

Your information will be encrypted.