Authorization of Representative

1

Patient Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Date of Birth* This field is required.

Date of Birth

4

Would you like to add an additional contact with whom we may discuss your information or add as an emergency contact?* This field is required.

YESNO

5

The information selected below may be disclosed to the designated individual.

Full Name Phone Number Relationship

All Health Information Clinical/Progress Notes Billing/Insurance Information Past/Present Medications Lab Results Also add this person to my emergency contact list

6

The information selected below may be disclosed to the designated individual.

Full Name Phone Number Relationship

All Health Information Clinical/Progress Notes Billing/Insurance Information Past/Present Medications Lab Results Also add this person to my emergency contact list

7

The information selected below may be disclosed to the designated individual.

Full Name Phone Number Relationship

All Health Information Clinical/Progress Notes Billing/Insurance Information Past/Present Medications Lab Results Also add this person to my emergency contact list

8

Date* This field is required.

Today's Date

9

Signature* This field is required.This authorization for the release of information will remain valid throughout your duration as our patient or until it is formally revoked in writing.

Clear