Authorization for Release of Medical Information

Authorization for Release of Medical Information

Complete this form to authorize AmpleHealth to release or obtain your medical information.
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorization Action
Name of Provider or Entity
Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Provider Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Provider Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Information to be Released (check all that apply)
Office Visit Notes Dates (if selected above)
Lab Results (specify)
Imaging/Radiology Reports (specify)
Other Information (specify)
Purpose of Disclosure
Other Purpose (specify)
Authorization Expiration
Expiration Date (if selected above)

MonthDayYear
Date
Patient/Legal Representative Signature
Date Signed

MonthDayYear
Date
If signed by Legal Representative, print name
Relationship to Patient
Other Relationship (specify)
Should be Empty: