-Administration Combination

Combo

Version: 3
Created: 12/30/2020
Patient Name Patient Name * First Last
Patient DOB Patient DOB * / MM / DD YYYY
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Release of Information
(Parent/Guardian or Patient (if 18 years old or older)) Release of Information
(Parent/Guardian or Patient (if 18 years old or older)) * 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:
Information is NOT to be released to anyone.

ONLY SELECT THIS IF YOU DO NOT WANT YOUR INFORMATION RELEASED TO ANYONE! If you would like other people to have access to your information DO NOT select this option.
Spouse
Spouse Name
Other
Other Names
Child(ren)
Child(ren) Name(s)
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.

**If patient is 18 years old or older they must sign the form** Clear

Full Name

I understand this is a legal representation of my signature.

**If patient is 18 years old or older they must sign the form**