Record Release Patient Details

Record Release Please release my healthcare information FROM:

Record Release Please send my healthcare information TO:

  •  The most recent 2 years of pertinent information (chart notes, and special testing)
  •  All medical records
  •  Specific Information (please specify)
  •  Sharing with other health care providers
  •  Personal use
  •  Legal investigation
  •  I am transferring my care to a new health care provider
  •  Other

I understand that i do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization, please read the Privacy Notice to patients posed at the facility where your information can be released. I understand that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization may re-disclose it, at which time it may no longer be protected under Privacy laws. 

 

THIS AUTHORIZATION WILL EXPIRE 90 DAYS FROM THE DATE SIGNED 

(Please click below to draw/upload sign)
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