Consent for Release of Medical/Billing Information Patients 18 Years of Age and Older

Patient Name

First Name:

Last Name:

Date of Birth:

Patient's Email:

Patient's Phone Number:

May leave me a message

Yes No

I understand that I have the option to share or keep my chart and billing records confidential since I am 18 years of age or older and agree with the following:

DO NOT Release any of my medical/billing information

OR

I hereby consent to the release of my medical/billing records to the following person(s):

Mother / Name:

Father / Name:

Other Person / Name:

Relationship to me:

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

Patient's Signature

Date:

You may revoke or change this consent in writing at anytime.

Office Use Only

Staff Member's Name

Date

Your information will be encrypted.