Authorization for Release of Medical Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
I hereby authorize Dripsy IV Bar to:
*
Release my medical information
Obtain my medical information
Both Release and Obtain my medical information
Information to be Released (check all that apply):
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Complete Medical Record
Immunization Records
Lab Results
Visit Notes
Treatment Records
Other
Authorization Terms:
I understand this authorization is voluntary.
I understand I may revoke this authorization in writing at any time.
I understand that once information is disclosed, it may be subject to re-disclosure and no longer protected by federal privacy regulations.
This authorization will remain valid for one year from the date of signature unless otherwise specified.
I understand that my treatment, payment, enrollment, or eligibility for benefits is not conditioned on signing this authorization.
Signature
*
Date
*
-
Month
-
Day
Year
Date
If signed by someone other than the patient, indicate your legal authority:
Please Select
Parent
Legal Guardian
Healthcare Proxy
Submit
Should be Empty: