Release of information

First Name(Required)

Date Of Birth(Required)

Last Name(Required)

Requestor Completing This Form (if applicable)

Phone Number(Required)

Name Entity releasing information(Required)

Relationship to Patient (ex: PCP)(Required)

Phone(Required)

Name of Entity releasing information

Relationship to Patient

Phone

Name of Person or Entity

Relationship to Patient

Phone

INFORMATION TO RELEASE: Please mark beside the types of information to be released:(Required)

Mental Health

Drug/Alcohol Abuse

Billing

Entire Record

Labs Results

Medication

PURPOSE FOR WHICH INFORMATION IS TO BE USED: *(Required)

Continuing Care/Treatment/Care Coordination

Disability Determination/Benefits

Other:

PATIENT/AUTHORIZED REPRESENTATIVE AUTHORIZATION

I understand that: (1) My signature on this form is strictly voluntary. (2) I may revoke this authorization at any time in writing, and if I do it will not have any effect on any actions taken prior to receiving the revocation. (3) If the requester or receiver is not a health plan or health care provider, the released information may be disclosed by the recipient and may no longer be protected by federal privacy regulations. (4) If I do not sign this form, my health care, the payment for my health care or my ability to enroll for benefits will not be affected. (5) I may inspect or obtain a copy of the health information that I am being asked to disclose.

Expiration: Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in any event will expire 365 days from the date hereof.

Signature of Patient (or Patient Representative if Minor) *(Required)

Date(Required)

Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.

* = Input is required

Release of Information Request