Release of Medical Information Form (generic with options)

Authorization for Release of Information
Patient full legal name*

First NameMiddle NameLast Name
Patient date of birth*

MonthDayYear
Patient home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requesting Records From:
Name:*
(Office, Doctor, School, Organization, etc)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This request applies to all prior healthcare information unless noted below:

0/100
Release Information to the Following:
Red Clover Pediatrics, PLLC*

5 Main St #444 N Bennington 05257 Fax 802-217-7284
Reason for release of records*

Transfer of CareOngoing medical careConsult
Consent*

1) I understand that authorizing disclosure of this health information is voluntary and I can refuse to sign this authorization. 2) I understand that information in my medical record may include information relating to sexually transmitted diseases, HIV status, mental health conditions, sexual health. 3) I understand that I have the right to revoke this authorization at any time and that I must do so in writing. I understand that my revocation will not apply to information that has already been released in response to this authorization.
Signature of patient or representative:*

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Relationship to patient:*
Should be Empty:

Authorization for Release of Information