Name* First Last Date of Birth* MM slash DD slash YYYY Release of InformationI authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:SpouseChild(ren)OtherInformation is not to be released to anyone.This Release of Information will remain in effect until terminated by me in writing.MessagesPlease Call My home My work My cell number PhoneIf unable to reach me You may leave a detailed message Please leave a message asking me to return your call Other ExplainThe best time to reach me isDayBetween (time)SignedDate MM slash DD slash YYYY WitnessDate MM slash DD slash YYYY
