Consent to Release Medical Information Form

Permission to Release Medical Information

Sunrise Medical
I blanks , hereby grant permission to:
Name of person you are granting permission to:

First NameLast Name
To receive:

Medical information on my behalf.Pick up prescription on my behalf.Verify appointments on my behalf.Receive copies of medical records on my behalf.I authorize permission to leave messages on my voice mail.I authorize permission to fax my medical information to my home.
I am providing my physician a copy of the following documentation to keep in my medical file:

Advanced DirectivesPower of AttorneyLiving Will
This form will remain in effect until I revoke permission with a written notification.
Signature

Clear
Date:

MonthDayYear
Date
Should be Empty:

Permission to Release Medical Information