Authorization of Release
Patient Information
Name
Last
First
D.O.B
Sex
Male
Female
Phone (Home)
Please enter a valid phone number.
Phone (Cell)
Please enter a valid phone number.
Address
Health Care Info
Give my health care information to:
Get my health care information from:
Doctor/Hospital/ETC
Address
City
State
ZIP
Phone
Please enter a valid phone number.
Fax
Please release the following information (check all that applies):
Laboratory Testing
Radiology Testing
Office Notes/ Procedures
Others (Please be specific)
Type a question
I DO
I DO NOT
WANT ANY INFORMATION REFERRING TO HIV ANTIBODY TESTING, OR TREATMENT/ DIAGNOSIS OF AIDS RELATED DISEASE TO BE DISCLOSED.
WANT ANY INFORMATION REFERRING TO DIAGNOSIS OR TREATMENT OF ALCOHOL/SUBSTANCE ABUSE TO BE RELEASED. I UNDERSTAND THAT SUCH INFORMATION CANNOT BE DISCLOSED WITHOUT MY SPECIFIC CONSENT.
WANT ANY INFORMATION REFERRING TO DIAGNOSIS OF MENTAL HEALTH TO BE RELEASED.
NEED TO REVIEW THE INFORMATION BEFORE FAXING.
Patient Signature
Date
-
Month
-
Day
Year
Date
Submit
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