Release of Information Form

Authorization for Release of Information
Name

First NameLast Name
Birth Date

MonthDayYear
Email
example@example.com
Type of Information to be Released
(List as specifically as possible, for example: name, dates of service, any documents).
Purpose for Information Release
(List as specifically as possible, for example: to receive benefits).
Release Information to the Following
Name

First NameLast Name
Organization:
Fax:
Email Address:
Delivery Method
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Continued Medical CareLegal PurposesInsurance PurposesPersonal InterestOther
Release Date Expiration

MonthDayYear
Date
I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.
Signature

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Authorization for Release of Information