Release of Information Form

Authorization for Release of Information
Patient Name

First Name Last Name
Birth Date

Month Day Year
Email
example@example.com
Type of Information to be Released
(List as specifically as possible, for example: name, dates of service, any documents).
Purpose for Information Release
(List as specifically as possible, for example: to receive benefits).
Release Information to the Following
Name

First Name Last Name
Organization
Phone Number
Email Address
Delivery Method
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Continued Medical Care

Continued Medical Care Legal Purposes Insurance Purposes Personal Interest
Release Date Expiration

Month Day Year
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.
Signature

Clear
Should be Empty:

Authorization for Release of Information