• Authorization to Release and Disclose Patient information

    Renew ENT & Hearing Center | Renew Plastic Surgery
  • I want to...*
  • Please select how you would like your information to be shared*
  • Records needed before...
     / /

  • Patient Information

  • Date of Birth*
     / /

  • Who has the information you want released?

  • Who is the receiving party?

    Where do you want the information to be sent?

  • Information to be released

    What information do you want sent? Please select all that apply
  • *

  •     
       Pick a Date   to   Pick a Date   

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  • Purpose of the Release

    Why is it needed?
  • Purpose of the Release*
  • I would like this form to be valid...
  • I would like this authorization to expire on...
     - -

  • This authorization lasts for one year after the date that you sign it unless you enter a different date here:   Pick a Date   

    • This authorization can be canceled in writing at any time. A cancellation will not change releases that happen before the cancellation. Please ask us how to cancel this authorization.
    • A photo copy of this authorization will be treated in the same way as an original. Released records may include records that were received from other organizations if these records have been filed in the record maintained about you.
    • Redisclosure of your information by the person or organization who receives your records under this authorization cannot be prevented and may not be covered by state and federal privacy protections after it is released. By signing this authorization you release Renew from any and all liability resulting from a redisclosure by the recipient.
    • Your signature indicates that you have read and understand the forms and authorize the release of your information.
  • Date*
     / /
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  • Should be Empty: