Authorization to Release Health Care Information

TO USE THIS REQUEST FORM, FILL OUT THE REQUIRED FIELDS, INPUT YOUR PAYMENT INFORMATION, AND CLICK SUBMIT. ONCE SUBMITTED, YOU WILL SEE A CONFIRMATION PAGE, INDICATING THAT YOUR PAYMENT WAS SUCCESSFUL AND THAT OUR OFFICE HAS RECEIVED YOUR REQUEST. PLEASE NOTE, OUTBOUND RECORDS REQUESTS REQUIRE PAYMENT OF THE $20 PROCESSING FEE BEFORE ANY REQUESTS CAN BE ACCOMMODATED.
SENDER'S NAME
Date

Month Day Year
Date
PATIENT'S FIRST NAME: *
PATIENT'S LAST NAME: *
PATIENT'S DATE OF BIRTH: *

Month Day Year
Date
WHO WILL THE RECORDS BE SENT TO?

ME (THE PATIENT) DOCTOR OR HOSPITAL ANOTHER PERSON
WHO SENDING TO (OUTPUT)
NAME OF PERSON WHO WE ARE RELEASING RECORDS TO (THE RECIPIENT) *
RECIPIENT'S ADDRESS *

Street Address

Street Address Line 2

City State

Zip Code
RECIPIENT'S PHONE NUMBER *
Please enter a valid phone number.
RECIPIENT'S FAX NUMBER
Please enter a valid fax number.
WHAT INFORMATION WOULD YOU LIKE RELEASED? *

ALL HEALTH CARE INFORMATION HEALTH CARE INFORMATION RELATING ONLY TO A SPECIFIC TREATMENT, CONDITION, OR DATE(S) (SPECIFY BELOW) OTHER (SPECIFY BELOW)
PLEASE SPECIFY WHICH INFORMATION YOU AUTHORIZE RELEASE OF (RELATED TO A TREATMENT, CONDITION, OR DATES) *
PLEASE SPECIFY WHICH INFORMATION YOU'D LIKE RELEASED (OTHER) *
SIGNER'S FULL NAME
SIGNATURE

Clear

RECORDS RELEASE PROCESSING PAYMENT

THERE IS A REQUIRED FEE OF $20 IN ORDER FOR OUR OFFICE TO PROCESS AND FULFILL YOUR REQUEST. ONCE SUBMITTED, YOU PAYMENT WILL BE PROCESSED, AND THE REQUEST WILL AUTOMATICALLY BE SENT TO OUR OFFICE.
WOULD YOU LIKE A RECEIPT AND CONFIRMATION EMAILED TO YOU? *

YES NO
WHAT IS YOUR EMAIL ADDRESS? *
example@example.com

Payment Summary *

Records Release Processing

$ 20.00

Total

$ 0.00

RECORDS RELEASE PROCESSING PAYMENT