Please enable JavaScript in your browser to complete this form.

Consent for Authorization or Release of Information and/or Medical Records

Communication with:

Release to and/or Obtain information from:

Specific items to be released and/or obtained to include information pertaining to:
Reason for Release:

Revocation of Consent: I understand that I may revoke this consent to release information at any time. I also understand that any release of information prior to my revocation shall not constitute a breech of my right to confidentiality. Unless I revoke this authorization prior to such time, this authorization shall expire six months after discharge from the clinic.

DISCLOSURES REQUIRING SPECIAL CONSENT: My signature below authorizes the release of healthcare information relating to the testing, diagnosis, or treatment for:

checkbox