MICHELLE RANDOLPH MD PC
is authorized to release patient health information as follows:
Psychotherapy Notes CAN NOT be released with this Authorization – provide a separate Psychotherapy Authorization to obtain those records
If this is not completed, Authorization expires one year from date of signature.
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND THAT I UNDERSTAND THIS AUTHORIZATION FORM
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.
A COPY OF THIS SIGNED AUTHORIZATION MUST BE PROVIDED TO THE PATIENT OR PATIENT REPRESENTATIVE
Your information will be encrypted.