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
Reason for release of records
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:
Relationship to patient:
Should be Empty:

Authorization for Release of Information