** If authorization is signed by a personal representative, the representative's authority is based on
(e.g., state law, court order, POA, etc
FEE SCHEDULE: State and Federal laws specify a reasonable fee may be charged to offset the cost associated with the reproduction of records. No fee shall be charged for reproducing and forwarding records directly to other physicians.
Notice to Patients: By choosing to utilize Email communication, you are acknowledging that email may not be completely secure. Selection of Email option and signature are documentation of patient and/or guardian acknowledgment of these risk and hereby grant permission to utilize email.
A fax copy, or photocopy of this consent shall be as valid as the original.