UVSC Authorization for Release of Information

Authorization for Release of Information

This is a consent for Release of Information (herein referred to as the “Release of Information”) about:
Name of Individual (patient): First Name*Last Name*
Date of Birth: Date
I authorize UVSC to obtain the following specific information: (check all that apply)

Other
This information may be used for the following purpose(s): (check all that apply)

Other
This Release of Information will be valid for 12 months from the date of signing this authorization. This Release of Information is not automatically renewable. It expires at the end of the period specified unless revoked in writing sooner.

I understand I have the right to see this information at any time. Any information already released may be used as stated on the consent. By my signature below, I affirm that I have read this release, or it has been read to me, and I understand its content.
Name of Patient, Applicant or Authorized person (if Applicant is under 18):

First NameLast Name
Signature of Patient, Applicant or Authorized person (if Applicant is under 18):
Date

MonthDayYear
Should be Empty: