Release of Information Paperwork

Release of Information Consent Form

Patient Name

I, the patient or legal representative of the patient, hereby authorize Dr. Nancy Shosid to disclose records and/or exchange information concerning myself or the patient to the following parties:

School Name, Contact Person and Phone Number

Medical Doctor Name, Contact Person and Phone Number

Therapist Name, Contact Person and Phone Number

Other Party Name, Contact Person and Phone Number

Patient or Legal Representative Electronic Signature

Maximum file size: 516MB

Date of Signature

Relationship of Legal Representative

Patient Date of Birth

If you are human, leave this field blank.

Release of Information Paperwork

Release of Information Paperwork

Clinic Location

Certified By

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