Patient Information

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

First Name

Last Name

Address

City

State

Zip

Date of Birth

Phone Number

Requestor Information

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

Relationship to Patient

First Name

Last Name

Organization

Address

Apartment or Suite Number

City

State

Zip Code

Email Address

Phone Number

Fax Number

Release Information

Reason for Disclosure

Your Reference Number

Authorization Expires On Date

Please specify that date on which this authorization to release records expires

Delivery Method

From Date of Service

To Date of Service

Documents Types Requested

Please select all that apply.

Comments and Exclusions

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.

Comments

Identity Verification

A copy of the patient's drivers 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