EW Authorization To Release Medical Information

EW Motion Therapy LLC
3125 Independence Dr. STE 300B // Birmingham Alabama 35209
Phone 205.879.7501// Fax 205.263.0994//ewmotiontherapy.com
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
Patient Name (please print):

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Email Address:
example@example.com
Clinic:
Patient's Address:
Email
Name of Doctor:
Fax Number:
Format: (000) 000-0000.
E-mail Address:
example@example.com
Date Range of Notes:
Signature of Patient or Authorized Agent
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name of Authorized Representative
Relationship to Patient
This authorization expires 90 days from the date signed.
Should be Empty:

AUTHORIZATION TO RELEASE MEDICAL INFORMATION