Consent For Medical Records

Consent For Medical Record

Authorization for The Release of Information

I hereby authorize

Name

To release from the medical records concerning

To Khushbu Shah, M.D. I understand that such disclosure will be made for the purposes of evaluation and/or continued treatment and will be limited to the following specific types of information

If other, please describe.

The consent is subject to revocation by the undersigned at any time except to the extent that action has been taken in reliance hereon and in any event, shall expire six (6) months from the date of this electronic signature.

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Date

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Consent For Medical Records

Authorization for The Release of Information

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