Release of Health Information

Name*
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Signature
May disclose my protected health information to:
Address
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
The type and amount of information to be used or disclosed is as follows:
- Most recent office notes
- XRAY/Imaging reports
- Lab results
- Consultation reports
- Entire records
- Other
List other information to be released:
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocations to the Privacy Officer. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my Insurer with the right to contest a claim under my policy.
Name of patient or patient's representative *
First Last
Relationship
Date
Date Format: MM slash DD slash YYYY