HEALTH INFORMATION

CONSENT TO RELEASE PROTECTED HEALTH INFORMATION

I hereby authorize The
following Physician / Hospital / Laboratory / Therapy or Imaging Facilities:

NAME:
ADDRESS:
PHONE:
FAX:
ATTN:

To disclose and release complete health record including, but not limited to, diagnoses, lab test /
results, radiology, pathology, treatment plan, and billing records for all conditions of myself, release to:

Heath Records Requested:

The information may be released or disclosed in printed and/or digital format. A photocopy
of this assignment is to be considered as valid as the original until revoked in writing.

Patients Signature (or Representative)

Date