Release of Information Form

Authorization for Release of Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Email*
example@example.com
Last 4 SSN*
Information to be released

All medical recordsSpecific record datesOther
Release Information to the Following
Name*

First NameLast Name
Organization
Phone Number*
Fax Number*
Email Address
Delivery Method
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Continued Medical Care

Continued Medical CareLegal PurposesInsurance PurposesPersonal InterestOther
Release Date Expiration*

MonthDayYear
Date
Consent

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.I understand that information released will include personal medical information including all medical and psychiatric information that was provided to medical professional
Signature*

Clear
DateTime
Should be Empty:

Authorization for Release of Information