• AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

  • If Barbara Nylander, what year was your last appointment?

  • Patient Information:

  •  -  -
    Pick a Date
  • Release records to: ALL INFORMATION MUST BE COMPLETED

  • I understand I have the right to:

    • Receive a copy of this authorization
    • Refuse to sign this authorization and that treatment, payment, enrollment in a health plan or eligibility for health care benefits may not be contingent on my signing this authorization
    • Revoke this authorization, except to the extent that the person(s) and/or organization(s) listed above have already made in reference to this authorization

    Records are not kept on site. We ask for 30 days to obtain your records from storage, copy and mail/fax. There will be a $30 fee for copying and transferring records. This must be paid prior to records being pulled. This can be paid by cash in the office or by credit card.

  • Name on card:
    Card Number:    EXP Date:  CCV: Signature for Payment:       

  • Clear
  • Should be Empty: