RELEASE OF INFORMATION

RELEASE OF INFORMATION FORM

John W. Grace, M.D., P.A.
By signing and dating below I,
Name *

First Name Last Name
Whose date of birth is,
Date of Birth *

Month Day Year
Date
Authorize John W. Grace, M.D., P.A. to disclose and/or obtain from the following sources: *
ALL MENTAL AND PHYSICAL HEALTH RECORDS INCLUDING ASSESSMENT, DIAGNOSIS, PSYCHIATRIC EVALUATION, TREATMENT PLANS, AND MEDICATION MANAGEMENT AS STAFF DEEMS APPROPRIATE.

REVOCATION:

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to John W. Grace, M.D., P.A. at 6226 West Corporate Oaks Drive, Crystal River, Florida 34429.

Expiration:

Unless sooner revoked, this authorization expires three years from the date of this signature.

Form of Disclosure:

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, in paper format or electronically.
Email *
example@example.com
Phone Number *

Area Code Phone Number
Signature *

Clear
Date *

Month Day Year
Date

$1.00 FEE FOR FIRST PAGE OF MEDICAL RECORDS RELEASED. $0.25/page after

USD Description

RELEASE OF INFORMATION FORM