• Patient Information Release Form

    Authorization for Release of Confidential Information: Please allow 24-48 Business hours to process. There will be a fee or records. In the case of a extensive file, fees made be added.
  • Fields with an asterisk (*) are required.

  • I hereby give my permission for

  • to receive and / or disclose any confidential information, verbal or written, regarding the above named patient to include :

  • Information to be released to:

  • I understand that the information obtained will be treated in a professional and confidential manner and will not be disclosed to any other person or agency without the written consent of the above named person or parent/guardian. This consent expires ninety (90) days from the initialed date below.

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  • Should be Empty: