Patient Information

Please complete this section with the name and contact information that your provider would have on file.

First Name

Last Name

Address

Apartment # / Suite

City

State

Zip

Date of Birth

Phone Number

Requester Information

The contact information for the person or organization that the records should be sent to:

Relationship to Patient

First Name

Last Name

Organization Name

Address

Apartment # / Suite

City

State

Zip

Email Address

Requester Phone Number

Requester Fax Number

Release of Information

Reason for Disclosure

Your reference number

Authorization Expires on Date

Please specify the date on which this authorization to release records expires.

Delivery Method

Document Types Requested

Please select all that apply.

From Date of Service

To Date of Service

Comments and Exclusions

Exclude Information

Select any sensitive information that, if available, you do not authorize us to release. If no information is selected you authorize us to release any and all information in your file.Please select all that apply.

Comments

Identity Verification

A copy of the patient's driver's license or other valid documentation (such as patient release documentation, letter of representation, etc.) is required for processing.

File Upload

. Only PDF, PNG, and JPG file types are accepted.

Signature

Signature of person requesting records

Signature

Providerflow

Create Signature

Search Lookup Values

Confirmation