Release form with Copay

* Any items marked with a red asterisk must be filled out, but any other items may be skipped.

Patient Full Name (First Last)*

To allow the report to be sent to the referral, please enter the Referral Name here:*

Or write "Do Not Release to Referral"

Date of Birth (Month/Day/Year)*

MM/DD/YYYY

I hereby authorize Dr. Azrin, Dr. Millsaps, or Leslie Kahn to obtain and to release my information to the following people, doctors, or facilities:

DO NOT LIST YOUR OWN NAME BELOW.

PLEASE LIST DOCTORS, HOSPITALS, AND FAMILY, YOU WOULD LIKE ME TO OBTAIN INFORMATION FROM AND RELEASE INFORMATION TO.

Name of Doctor or Person, or Facility, authorized to obtain and to release information (list family, doctors, hospital or facility, individuals or organizations):*

List 1 Doctor or Family or Hospital for obtain /release of information

Phone (if you know it)

Fax (if you know it)

Address (if you have it)

City

State

Zip

Is there a 2nd individual or organization that we need to get or give information to?

YesNo

2nd) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization):

Phone

Fax (if you have it)

Address (if you know it)

City

State

Zip

Is there a 3rd individual or organization that we need to get or give information to?

YesNo

3rd) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization):

Phone

Fax (if you have it)

Address (if you know it)

City

State

Zip

Is there a 4th individual or organization that we need to get or give information to?

YesNo

4th) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization):

Phone

Fax (if you have it)

Address (if you know it)

City

State

Zip

Is there a 5th individual or organization that we need to get or give information to?

YesNo

5th) Name or Facility authorized to obtain and to release information (list your referral doctor, family, other doctor, hospital/facility, or other individual or organization):

Phone

Fax (if you have it)

Address (if you know it)

City

State

Zip

You may Enter or Skip entering the e-mail address below:

** If you enter your e-mail address, be sure to type your e-mail address twice below, just to confirm that we have the right e-mail address.

Optional: Email (Test results, receipts, and forms will be sent to this email address):

Confirmation EmailIf you type your e-mail above, be sure to type it again to confirm

If you would like to pay any past or upcoming copays, but don't know the amount, please call 205-329-7815 from 8am-noon or from 1pm-4pm to find out what you owe.

If you know your past balance due, or your upcoming appointment copay, then please enter the amount here:

USDPlease enter your copay amount here

Enter Firstname, Lastname, Credit Card Number, Security Code, Expiration, and Credit Card Zipcode

Optional: Social Security Number

Name of patient or responsible party signing below:

Signature of patient or responsible party*

Clear

Date

DateHourMinutesAM/PM Option

If signed by patient's representative, please provide a description of representative's authority to act for the patient:

You may specify which years to include for records requests (optional)?

Optional: Do you have detailed restrictions you insist on adding about releasing information?

No, I do not need to specify additional detailed restrictions.Yes

Optional: You may list restrictions to this release form, but you must also speak to someone in our office and verify that providers and especially staff understand and are able to agree your restrictions:

Release of Information

Enter Firstname, Lastname, Credit Card Number, Security Code, Expiration, and Credit Card Zipcode