Authorization to release healthcare information

Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I request and authorize Jacobs Audiology, LLC to release healthcare information of the patient named above to:
Name*
Phone Number*

Area CodePhone Number
This request and authorization applies to:

Healthcare information relating to hearing loss and treatment.
I authorize the release of all records regarding hearing health treatment to the person/s clinic listed above:*

YesNo
Signature*

Clear
Date*

MonthDayYear
Date
This authorization expires 90 days after it is signed
Should be Empty: