Release of Information Form

Authorization for Release of Information
Name
First NameLast Name
Birth Date
MonthDayYear
Email
example@example.com
Type of Information to be Released
(List as specifically as possible, for example: name, dates of service, any documents).
Purpose for Information Release
(List as specifically as possible, for example: to receive benefits).
Release Information to the Following
Name
First NameLast Name
Organization
Phone Number
Email Address
Delivery Method
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Continued Medical Care
Other
Release Date Expiration
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Consent
Signature
Clear
Should be Empty:

Authorization for Release of Information