-Administration Combination
Combo
Version: 2
Created: 1/2/2019
Patient Name
Patient Name
*
First
Last
Patient DOB
Patient DOB
*
/
MM
/
DD
YYYY
Release of Information
(Parent or Guardian)
Release of Information
(Parent or Guardian)
*
First
Last
Email
*
I, (name above) authorize the release of Protected Health Information including the diagnosis, records; examination (s) rendered to me or my child as well as prescriptions and claims/billing information. This information may be released to:
Spouse
Spouse Name
Child(ren)
Child(ren) Name(s)
Other
Other Names
Information is NOT to be released to anyone.
This Release of Information will remain in effect for 12 months or upon the minor's age of majority, whichever shall come first unless effectively revoked in writing before that date or event.
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
Date
Date
*
/
MM
/
DD
YYYY