RELEASE OF INFORMATION FORM

LUNA LACTATION & WELLNESS: RELEASE OF HEALTH RECORDS AUTHORIZATION FORM

Luna Lactation and Wellness 1906 NW 25th Ave #10 Portland, OR 97210 p.360.830.6455 f.360.543.7085 e.support@lunalactation.com
Patient Name: *

First Name Middle Name Last Name Suffix
Patient Email *
example@example.com
Patient Phone Number *

Area Code Phone Number
Patient Date of Birth: *

Month Day Year
Please send my information to:
Please obtain my information from:
Please provide contact info for the provider or practice that you want Luna Lactation to release/obtain info to or from:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Provider's Fax#

Area Code Phone Number
Provider's Phone#

Area Code Phone Number
For the purpose of: *

At my Request For Coordination of Care
I understand that:

1. I understand that signing this authorization is voluntary and that treatment or payment for treatment cannot be conditioned on the signing of this authorization.

2. I understand the information disclosed under this authorization might be re-disclosed by the recipient.

3. I have the right to revoke this authorization at any time, in writing, to Luna Lactation and Wellness.

4. I authorize and request the disclosure of all protected medical information inlcuing but not limited to chart notes, labs, care plans, health records, medication lists, etc.
By typing your name here, you agree to the release of records: *
Should be Empty:

LUNA LACTATION & WELLNESS: RELEASE OF HEALTH RECORDS AUTHORIZATION FORM