Release of Information Form

Authorization for Release of Information
Name

First NameLast Name
Other Name(s) Used (maiden or previous married name):
Birth Date

MonthDayYear
Gender:
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Type of Information to be Released:
(List as specifically as possible, for example: name, dates of service, any documents).
Purpose for Information Release:
Release Information to the Following
Receiving Location:
Delivery Method
Name

First NameLast Name
Organization
Phone Number
Fax Number
Email Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Release Date Expiration

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

I request and authorize the Fergus County Nurses Office to release this patient’s medical and/or immunization record from Fergus County Health Department and/or Montana’s Immunization Information System (IIS), imMTrax, to the person or agency indicated. I declare the information provided is correct and that I am authorized to sign this release on the patient’s behalf. I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.
Name of Requestor (Patient or Parent, Legal Guardian or Managing Conservator for a Child)

First NameLast Name
Signature of Patient (or Parent, Legal Guardian or Managing Conservator for a Child)
Should be Empty:

Authorization for Release of Information

Release Information to the Following