RELEASE OF INFORMATION

I hereby request and authorize to release
medical information concerning:

NAME:

ADDRESS:

CITY: STATE: ZIP:

DATE OF BIRTH:

Please release the following information:

Please send this information to:

FACILITY NAME:

ADDRESS:

CITY: STATE: ZIP:

PHONE: FAX:

Authorization must be signed by the patient or by a legal guardian for medical records to be
released.

Patient/Guardian's SignatureDate