Request for Confidential Communication
Patient Information
Last Name
First Name
MI
Date of Birth
Address
City
State
Zip
Release of Information
I authorize the release of information, including the diagnosis, records, examination rendered to me and claims information.
Information is not to be released to anyone
This
Release of Information
will remain in effect until terminated by me in writing or three (3) years after the date signed, whichever is first.
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship
Patient Signature
(required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.
Date