Authorization to Release Health Care Information

Patient Name

Maiden Name

Date of Birth

Social Security #

I request and authorize

to release health care information of the patient named above to:

Physician / Practice / Patient:

Address

FAX #

Phone #

This Request & Authorization Applies to:

Health care relating to the following treatment, condition or date:

All Health Care Information

Other:

I understand that this information may include reference to or treatment of drug or alcohol abuse, psychological illness, or test results for HIV/AIDS. I understand that there may be a charge for these records and that there is a customary processing period. I further understand that I may revoke in writing this consent at any time.

Purpose of disclosure:

By checking this box and typing my name, below,

I certify that I am the above named patient, and that I am consenting to this authorization to release my medical records.

Type Your Name as Digital Signature & Consent:

Date

If you are human, leave this field blank.

Authorization to Release Health Care Information

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706.324.0471