Neuropsychological Evaluation Results Release Form
Complete this form to authorize the release of your neuropsychological evaluation results to a specified recipient. Only the information below is required for this release.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Recipient Full Name or Organization
*
Recipient Contact Information (Email, Phone, or Address)
*
Results to Be Released
*
Preferred Method of Release
*
Please Select
Mail
Email
Fax
In-person Pickup
Purpose of Release
*
Please Select
Personal Use
Medical Care Coordination
Educational Planning
Legal Purposes
Other
Expiration Date of Authorization
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Patient or Legal Representative
*
Submit
Submit
Should be Empty: