Authorization to Release Medical Information

Authorization to Release Medical Information
Patient Full Name:*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Date
Patient Social Security Number:*
Patient Phone Number:*
Please enter a valid phone number.
Patient Email:
example@example.com
Patient Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Aliases (Click Next if Not Applicable)

First NameLast Name
Name of Guardian or Legal Representative (Click Next if Not Applicable)

First NameLast Name
Guardian of Phone Number or Legal Representative:
Please enter a valid phone number.
Guardian of Email or Legal Representative:
example@example.com
I hereby authorize the following health care professional, medical facility, mental health facility, laboratory, paramedical facility, medical examiner, medical records service, prescription history clearing house, consumer reporting agency, employer, or family member to release.
Check One:*

My Entire Health RecordMy Medical Records as Described on the Following section
Person or Organization to Release Information:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Patient Signature:*

Clear
Date of Signature:*

MonthDayYear
Date
Should be Empty: