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

MonthDayYear
Date
PATIENT'S FIRST NAME:*
PATIENT'S LAST NAME:*
PATIENT'S DATE OF BIRTH:*

MonthDayYear
Date
WHO WILL THE RECORDS BE SENT TO?

ME (THE PATIENT)DOCTOR OR HOSPITALANOTHER 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

CityState

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 INFORMATIONHEALTH 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?*

YESNO
WHAT IS YOUR EMAIL ADDRESS?*
example@example.com

Payment Summary*

Records Release Processing

$20.00

Total

$0.00

RECORDS RELEASE PROCESSING PAYMENT