Healthcare Transfer Authorization Form
Complete this form to authorize the transfer of your healthcare records or coordinate transfer of care between providers.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Contact Email
*
example@example.com
Current Healthcare Provider Name
*
Current Provider Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Receiving Healthcare Provider Name
*
Receiving Provider Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Records or Care to Be Transferred
*
Reason for Transfer
I authorize the transfer of my healthcare records or coordination of care as described above.
*
I authorize
Submit Authorization
Should be Empty: