Consent to Release Information Consent to Release Information Authorization Form For Release of Protected Health InformationBy signing this form, I authorize you to use and disclose the protected health information described below to family members or other persons of my choosing as designated on the document.Patient Name :*Date:*01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901daymonthyearMy PREFERRED Method of Contact is:(Check one that is PREFERRED & provide all additional contact information below)Telephone (Cell/Home/Work) My number is: Area Code - Phone Number Text Message. My number is : Area Code - Phone Number E-Mail. My e-mail address is : Check all that apply below:It is O.K. to leave me a message with detailed information.It is O.KIt is Not O.KIt is O.K. to contact me at work. My number is: It is O.KIt is Not O.kIt is O.K. to leave me a message at work with detailed information. It is O.KIt is Not O.KIt is NOT O.K. to leave me a message at work with detailed information.It is O.KIt is Not O.KI authorize you to discuss my medical history and release any and all medical information to the following individuals: (fill in all that apply)1. My spouse, whose name is: First Last Phone : Area Code - Phone Number 2. My spouse, whose name is: First Last Phone : (2) Area Code - Phone Number 3. My spouse, whose name is : First Last Phone : (3) Area Code - Phone Number No one other than myselfYesFill in any other name you desire : Signature of Patient or Personal RepresentativeDate :01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / daymonthyearSubmitReset
