Urgent Care Release of Information Authorization Form

Urgent Care Release of Information Authorization Form
Complete this form to authorize the release of your urgent care visit information to a designated recipient.
Patient Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Urgent Care Visit Date(s) or Date Range
Records or Information to Be Released
Recipient Name or Organization
Purpose of Release
Authorization Expiration Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: