Upload Patient ID and Insurance Card(s)
I, the patient, Date of Birth ,
Phone # , Hereby Authorize:
To release my health information as identified below for the following purpose(s).
Continuation of Care
Information to be disclosed.
Please check all appropriate boxes.
Person / Organizations TO Receive Information - Contact Information
Name of Persons / Organization
Complete Address / Phone
The staff may discuss my medical condition and treatment with those persons listed above. This consent is subject to revocation at any time except to the extent that the persons.organization which is to make the disclosure has already taken action in reliance on it.
Re-Disclosure Prohibited: This information has been disclosed from records whose confidentiality's protected by state or federal law (42 CFR part 2). These laws prohibit making any further disclosure of this information without the specific written consent of the person whom it pertains, or as otherwise permitted by law.
I understand I may revoke this consent at any time. This consent expires on or in 180 days unless otherwise specified.
By typing you name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application
Patient Signature :
If you have been web enabled please use the patient portal link below to communicate with staff and or physician(s).
Go to Patient Portal