Release Form

Release Form
Patient Name *
DOB *
Phone *
I hereby authorize Waterville Audiology to release my Medical Records to: I hearby authorze Waterville Audiology to request my Medical Records from:
Release to Entity Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Information to be released:

Hearing Test/Audiogram Hearing Aid Information
Entity Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax
Please enter a valid phone number.
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 45c 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.
- 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 *

Clear
Date *

Month Day Year
Date
Signature of Patient's Authorized

Clear
Date

Month Day Year
Date
105 Kennedy Memorial Drive, Waterville, ME 04901

208-872-0320

www.watervilleaudiology.com
Should be Empty:

Release Form

PLEASE FAX RECORDS TO 207-872-0330