Authorization for Release of Medical Information

Please correct the errors described below.

Please note: This form must be filled out in its entirety to be valid.

I, the undersigned, do hereby authorize you to release the medical record of:

Information to be Released

Reason for Release

I understand that I may revoke this consent at any time except to the extent that action has been already been taken in Reliance on it. I further understand that there may be a charge for preparing the information to be released. Applicable charges are in keeping with guidelines issued by the State Board of Medical Examiners.

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