Medical Information Release

Medical Information Release

Agreement to do business with Dr. Daniel Farkas, Back to Health Natural Solutions LLC.
Name *

First Name Last Name
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
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Release of Medical Information
Permission to get records
I, (patient name)*, with a date of birth, (patient's DOB)*, give my permission for(doctor's or hospital name who has records) * to give my medical records (as described on p. 2) to Dr. Daniel Farkas so that he can better understand my condition and help me.
Permission to get sensitive information
By putting my initials by each item below, I understand that I give permission for records to be sent that may contain information about:
Initials* my mental health
Initials* transmittable disease I may have like HIV/AIDs,
Initials* genetic records, and/or
Initials* drugs and alcohol records.
I understand that:
- I do not have to give my permission to share these records.
- If I want to take away the permission for my doctor to get these records, I need to talk to my doctor or a staff person and sign a paper.
- This form is only good for 3 months from the date I sign it.
Patient's Signature *

Clear
Date: *
Authorized Representative's Signature

Clear
Date:
Relationship of Authorized Representative
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Should be Empty:

Release of Medical Information