AUTHORIZATION TO RELEASE INFORMATION
Patient Name (Last):
(First):
DOB:
SS#:
Cell #:
Day Phone #:
INFORMATION REQUESTED FROM:
Name:
Address:
City:
State:
Zip Code:
Phone:
Fax:
INFORMATION REQUESTED TO:
Information I would like sent / requested:
Copies of pertinent info only (H&P, OP reports, Labs, Imaging Reports)
Copy of entire medical record
Other (Please Specify)
Patient Signature: (Your Name is Your Electronic Signature)
Date: