(The execution of this form does not authorize the release of information other than the terms specifically
I request and authorize the above-named doctor or health care provider to release the information
specified below to the organization, agency or individual named on this request. I understand that the
information to be released includes information regarding the following condition(s):
PURPOSE OR NEED FOR WHICH INFORMATION IS TO BE USED:
may not be used with the same effectiveness as an original.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.