Patient Release Form

Patient Release Form

P: (207) 872-0320 F: (207) 872-0330
Name:

First Name Last Name
DOB:

Month Day Year
Date
Age:
Home Phone #:
Please enter a valid phone number.
Work #:
Please enter a valid phone number.
Cell #:
Please enter a valid phone number.
Email:
example@example.com
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone #:
Please enter a valid phone number.
PCP Office Location:
Please explain:
I hereby authorize Waterville Audiology to release my Medical Records to:
Release to Entity Name:
Address
City
State
Zip
Fax
Information Requested

Hearing Test/Audiogram Hearing Aid Information
I hereby authorize Waterville Audiology to request my Medical Records from:
Release to Entity Name:
Address
City
State
Zip
Fax
Information Requested

Hearing Test/Audiogram Hearing Aid Information
PLEASE FAX RECORDS TO 207-872-0330

This consent is effective until terminated by the patient. The fees associated with copies of transferred records is $5.00 for first page and 45¢ for each page after.
I Understand That:

■ I can revoke all or part of this authorization at any time by notifying Waterville Audiology in writing.
■ I can refuse to disclose all or some of my treatment records

■ Our office routinely makes reminder telephone calls to confirm appointments. If we reach an answering machine, we will leave a message with our practice name and the time and date of your appointment. If you do NOT want us to leave
you a message, please contact the front desk.

■ A refusal or revocation to release some or all information may result in improper diagnosis or treatment, denial of insurance coverage or a claim for health benefits, or other adverse consequences.

■ I can have a copy of this form upon request.
Signature for Patient Privacy Notice (HIPPA)

Clear
Date

Month Day Year
Date
Signature of Patient's Authorized Representative

Clear
Date

Month Day Year
Date
Should be Empty:

Patient Release Form

I hereby authorize Waterville Audiology to release my Medical Records to:

I hereby authorize Waterville Audiology to request my Medical Records from:

PLEASE FAX RECORDS TO 207-872-0330