brodnermd.com - Information Release Form

Release of Medical Information
I hereby authorize: Name of personand any of his employees to disclose health information from my medical records.
Patient Name
Date of Birth
Date of Treatment
Release Information To
This request permits the practice to use and disclose my health information to person or persons noted above regarding my condition. A patient has the right to request the restriction uses and disclosures of health information for treatment, payment and health care operation purposes. This request to release confidential information may be revoked by me in writing, at any time, except to the extent that action has already been taken.

I understand that these records are protected under federal and state law and cannot be disclosed without my consent unless otherwise provided by law. Having read this request for release of medical information, I hereby release and hold harmless to the practice, its employees, staff and agents in connection with the disclosure of information set forth relating to these medical records.
Patient Name (Print)
Date

MonthDayYear
Date
Signature of Patient
Date

MonthDayYear
Date
Witness
Date

MonthDayYear
Date
Should be Empty:

Release of Medical Information