Release of Information Form

Name

First NameLast Name

Birth Date

MonthDayYear

Email

example@example.com

Name

First NameLast Name

Organization

Phone Number

Email Address

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Release Date Expiration

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.I hereby authorize the listed medical facility or health care provider to release health information about me. Including insurance records or medical records sent by other health care providers.

I further understand that my medical record may include one or more of the following: The above person/organization, it's employees, representatives and any other persons performing services for them or on their behalf, may need to obtain, use or disclose any and all information about my physical and mental health, including but not limited to, services for preventative, diagnostic and therapeutic care, tests, counseling, and medical prescriptions for the purpose of:I understand and agree that health information about me, which is used or disclosed pursuant to this authorization, may be subject to re-disclosure by the recipient and may no longer be protected by law. This Authorization is valid. A copy, electronic copy, image or facsimile of this authorization is as valid as the original. I have right to revoke this authorization in writing at any time. I acknowledge that such a revocation is not effective to the extent the above person/organization has relied on the use or disclosure of information about my health does not apply to this authorization. By my signature below, I acknowledge that any prior agreement I have made to restrict or limit the disclosure information about my health does not apply to this authorization.I have read( or have had read to me) this authorization, and I agree to it's terms as indicated by my signature below. I am entitled to a copy of this authorization.

Signature

Authorization for Release Medical Information

Release Information to the Following