Release of Information Form

Authorization for Release of Information
Name *

First Name Last Name
Birth Date *

Month Day Year
Email
example@example.com
Type of Information to be Released
Labs, Pathology, Imaging, Op notes, Progress notes for the past 5 years (List as specifically as possible, for example: name, dates of service, any documents).
Purpose for Information Release
For continued care at another facility (List as specifically as possible, for example: to receive benefits).
Release Information to the Following
Name
Organization
Phone Number
Fax

Area Code Phone Number
Delivery Method
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Continued Medical Care

Continued Medical Care Legal Purposes Insurance Purposes Personal Interest
Release Date Expiration
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. I authorize disclosure of health information that contains records regarding mental health, drug/alcohol abuse or treatment, HIV/AIDS, and genetic testing.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Authorization for Release of Information