SFM Clinical Research, LLC

Release of Information Authorization Form
SFM Clinical Research

I, (Patient Name)
hereby authorize SFM Clinical Research, LLC to:

Records Desired

It is understood:
  • That the recipient of the protected health information under this authorization should not re-disclose the information without a written authorization.
  • Health Care Provider will not condition the provision of care or receipt of benefits on the signing of the authorization.
  • Patient will receive a copy of the completed authorization form upon request.
  • Patient may revoke this authorization by requesting in writing.
This authorization expires (choose one)

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
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