Request of Information Form

this form is going to be used to grant the release patient information.

  • DD slash MM slash YYYY
  • Authorization FOR Release/ exchange of highly confidential health information. ( evaluation, diagnoses, mental health care)
  • MM slash DD slash YYYY
  • DD slash MM slash YYYY
  • I have the right to inspect and copy the health information to be released and if I do not sign this Authorization, the institution named above the information. The above-named person/institution will not refuse to treat me based on whether I agree to allow my health information to others. I also understand that this Authorizationnis subject to revocation/ withdrawal by me at any time in writing to the medical record contact except to the extent that action has already been taken to release this information. This authorization shall remain valid unless revoked.
  • MM slash DD slash YYYY
    This release is valid for one (1) year from the date signed unless I fill in an early date.