Release Confidential Information from Virtue Medicine Provider

Authorization to Release Confidential Records or Information

221 E. College. St., Ste. 212 Iowa City, IA 52240 (319)338-5190
Client
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider Name*, at Virtue Medicine, P.C. is hereby authorized to release information regarding the above named client from her records to the following individual or entity:
Name/Entity to Receive or Access Confidential Records:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Email
example@example.com
Fax
for the following purpose(s)

Other
The information to be disclosed, concerning the time between Date and Date .
Other
If a medical release, HIV-related and drug/ alcohol info will be released under this consent unless indicated here
I have had explained to me and fully understand this request/authorization to release records and information, including the nature of the records, their contents, and the likely consequences and implications of their release. I release the source of the records from any and all liability incurred through release of my information. This request is entirely voluntary on my part. I understand that I may revoke this consent at any time except to the extent that action based on this consent has already been taken.
This consent will expire on Date, OR 2 years from the date on which it is signed, unless revoked in writing. I agree that a photocopy of this form is valid, if signed by client or legal guardian.
Signature of client
Printed name
Today's Date

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

Authorization to Release Confidential Records or Information