Release of Medical Information to Another Facility Form

Last Name *

First Name *

MI *

Date of Birth *

Address *

Address

Line 1

Line 2 (optional)

City

State/Province

Zip/Postal

Phone # *

Email *

Authorize Records Released to:

Name

Via:

Mail

Email

Fax

Address: *

Address:

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Email:

There is some level of risk that information in email could be read by someone besides you. If requesting us to email your records to you, please indicate how you would like to receive your health information.

Encrypted

Unencrypted

Fax Number:

Records To Be Released From Dates Of Service *

From Date

To: *

To Date

Records To Be Released: *

Purpose For Release: *

Release Records From: *

Digital Signature of Patient *

IF RECORDS ARE 40 OR MORE PAGES, THERE WILL BE A CHARGE OF $15.00 PLUS POSTAGE. PREPAYMENT IS REQUIRED.

If signed by person other than patient, state relationship:

Date

This authorization will expire one year from signature date. I understand that I may revoke this authorization at any time by providing my written revocation. This release is executed in conformity with Wis. Stats. §§146.81-83, 51.30, 252.15 and 102.13.