Authorization to Release Medical Records
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Full Name of Organization
Facility Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
Information Authorized
Please Select
Medical Examination
Psychiatric Evaluation
Psychological Evaluation
Screening Evaluation
Progress Notes
Medication
Financial
Diagnosis
Summary of Treatment
Summary of Discharge
Okay to Disclose all Information
Please select
Signature
Today's Date
-
Month
-
Day
Year
Date
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Should be Empty: