Authorization for Release of Medical Information
Please complete this form to authorize the release of your protected health information to a specified recipient.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email Address
example@example.com
Recipient Name (Person or Organization authorized to receive information)
*
Recipient Contact Information (address, phone, or email)
*
Type of Information to be Released
*
Medical records (all)
Lab results
Imaging reports
Billing information
Other (please specify below)
If 'Other', please specify the information to be released
Purpose of Release
*
Personal use
Insurance
Legal
Transfer of care
Other (please specify below)
If 'Other', please specify the purpose
Expiration Date of Authorization
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Patient (if not self)
*
Please Select
Self
Parent/Guardian
Power of Attorney
Other (please specify below)
If 'Other', please specify your relationship to the patient
Please provide any specific instructions or limitations for this authorization
Signature of Patient or Authorized Representative
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Authorization
Submit Authorization
Should be Empty: