I authorize the release of information including the diagnosis, records, examination rendered, and claims information to: (list names and relationship)
eg "Norm Stewart, father"
This RELEASE OF INFORMATION will remain in effect until terminated by me in writing.
METHODS OF CONTACT
Enter your number
Also enter if there are 'better days' to reach you.
Enter "none" if you do not have access to email. Please update this form once you get an email address
REMINDER: Patients MUST update this form whenever there is a change in phone numbers or people we can contact.