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.
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.