• Release Form

  • 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.
  • Clear
  •  -  -
    Pick a Date
  • Clear
  •  -  -
    Pick a Date
  • 105 Kennedy Memorial Drive, Waterville, ME 04901

    208-872-0320

    www.watervilleaudiology.com

  • Should be Empty:
Jotform Logo
Now create your own Jotform - It's free! Create your own Jotform