Auth Release Records From Us Pots

0323 - Auth Release Records From Us

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient’s Full Name:

Date of Birth:

Month

Day

Year

Previous Name:

Social Security #:

Full Name:

Full Address:

Phone (For SMS if appicable):

Fax:

Email:

The request and authorization applies to:

Healthcare information relating to the following treatments, conditions, and/or dates:

All healthcare information

Date ranges (if applicable) From:

Other:

I authorize the release of my records to the person(s) listed above.

Yes

Patient Signature:

Date:

Witness Signature:

Date:

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED