Release of Information Form

Authorization for Release of Information
Name

First NameLast Name
Birth Date

MonthDayYear
Email
example@example.com
Last 4 SSN
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 NameLast Name
Organization
Phone 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.
Signature

Clear
Should be Empty:

Authorization for Release of Information