Release of Information Form

Authorization for Release of Medical Records
Name of Client*

First Name Last Name
Birth Date*

Month Day Year
Name of Person Completing Form (if different than client):

First Name Last Name
Relationship to client if person completing form is not client
Email*
example@example.com
Last 4 SSN of Client*
Type of Information to be Released*
(List as specifically as possible, for example: name, dates of service, any documents).
Purpose for Information Release*
(List as specifically as possible, for example: to receive benefits).
Release Information to the Following
Name*

First Name Last Name
Phone Number*
Email Address*
Delivery Method*
Records are being request for the following purpose:*

Continued Medical CareLegal PurposesInsurance PurposesPersonal Interest
Where records should be sent (if being mailed):

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Release Date Expiration (recommendation is one year past today's date but cannot be longer than two years past today's date)*

MonthDay Year
Date
Consent*

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.
Consent*

I understand that there is no charge for my records to be sent electronically by secure email. However, I will be charged $15 for the first 10 pages and $.50 for each additional page if I request that my records be mailed to me or to someone else.
Consent*

I understand that if I choose to have my records sent electronically via encrypted email, there is a risk that electronic communications may be compromised, unsecured, and/or accessed by a third party despite Creekside sending such records in a secure and encrypted format. If I chose this format, I acknowlege those associated risks.
Signature*

Clear
Should be Empty:

Authorization for Release of Medical Records

Release Information to the Following