TAG ROI

Patient Name*

First NameLast Name
Maiden/Other Name
Date of Birth*

MonthDayYear
Date
SSN
I hereby authorize and request the release of the following information:*

All Patient InformationPatient Information for visit date(s) of: (enter below)All Billing StatementOther
visit dates from Date to Date
Purpose for release of information
Upon request, you may limit the amount of time that this consent for release of information is valid. You may revoke his authorization and writing at any time. I understand that the revocation will not apply to information that has already been released. I understand that authorizing the disclosure of this information is voluntary. I can refuse to sign authorization and note that I do not need to sign for shot treatment. I understand that any disclosure of information carries with it the potential for unauthorized re-disclosure by the recipient. Photocopies or facsimile of this authorization shall be considered in agreement like the original document.
Signature

Clear
Date*

MonthDayYear
Date
Relationship to patient (If parent of guardian)
Should be Empty: