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

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.

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

Confirmation Email example@example.com

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:

USD Please enter your copay amount here

Enter Firstname, Lastname, Credit Card Number, Security Code, Expiration, and Credit Card Zipcode
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Birth Date (you must enter birth date)

Date

Social Security Number

Birth Date

Date

When we ask doctors to send us your records, what years should we request?

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

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

Please list any restrictions on this release of information (you must also speak to someone in our office and verify that providers, and especially that staff understand and are able to agree your restrictions):

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 FAMILY, DOCTORS, OR HOSPITALS 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?

Yes No

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?

Yes No

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?

Yes No

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?

Yes No

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

Name of patient and/or responsible party signing below:

Signature of patient or responsible party *

Clear

Date

Date Hour Minutes AM/PM Option

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

Amber Fox, LPC

Amber Fox, LPC

Amber Fox, LPC

This release also includes Amber Fox, LPC.

Release of Information