Authorization to Release Healthcare Information

Patient's Name:

Date of Birth:

Previous Name:

Social Security #:

I Request and Authorize:

to release healthcare information of the patient named above to:

Name:

Address:

City:

State:

Zip Code:

This request and authorization applies to:

All Healthcare Information:

Healthcare information relating to the following treatment, condition, or dates:

If checked, please specify:

Other:

If checked, please specify:

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.

Patient's / Legal Guardian's Signature:

Date:

Your information will be encrypted.