Authorization to Release Healthcare Information

Authorization to Release Healthcare Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SSN#
MR#
Email
example@example.com
Authorization
By signing this form, I request and authorize release and management of healthcare information between Dr. Robin Shaw and

(add who you want information shared with below)
Name:
Person to receive protected information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
This document expires in one year from today's date unless otherwise specified. I also understand I may revoke this authorization at anytime by notifying my provider.
Expires on:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
This release of information applies to:

Other
Information will be released for the purposes of:

Other
This release of information

Other
I, the undersigned, understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it, and that in any event, this authorization shall expire six (6) months after the date signed unless otherwise specified.
Please specify date (if applicable)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and to the best of my knowledge. Re-disclosure of my medical records by those receiving the above-authorized information may not be accomplished without my further written consent. When services are provided to more than one person simultaniously, legally neither the therapist or the records will represent either individual separately.
Patient Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Witness Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: