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INTELLIGENT QUESTIONNAIRE FOR

AUTHORIZATION FOR EMPLOYER TO RELEASE MEDICAL INFORMATION - $9.95

PRINT YOUR DOCUMENT IN MINUTES AFTER ANSWERING THE QUESTIONS BELOW!  

INFORMATION REGARDING PATIENT(Person Authorizing The Release of Medical Information About Himself/Herself)
First Name:

Last Name:

 
INFORMATION REGARDING ENTITY OR PERSON THAT WILL RELEASE MEDICAL INFORMATION
Name:
     Company Company Name:
  Person First Name:
    Last Name:
Address:
City:
State: Zip Code:
 
INFORMATION REGARDING ENTITY OR PERSON THAT WILL RECEIVE MEDICAL INFORMATION
Name:
     Company Company Name:
  Person First Name:
    Last Name:
Address:
City:
State: Zip Code:
 
TYPE OF MEDICAL INFORMATION TO BE RELEASED
What medical information will be released? *
Please check all that apply:
Pathology Reports
Progress Notes Lab Reports/Tests
X-ray Reports History & Physical Inpatient Data
Immunizations Discharge Summary Outpatient Data
Emergency Record Radiology Reports Other - Fill in Below *
Consultation Reports Operative Reports
 
* Note: If you select to release "Other" medical records, do not fill in the blank with information relating to HIV, drug/alcohol abuse, mental health, or developmental disabilities, as this form is not intended for the release of such medical information.
 
* Note: Even if you select to release "Complete Medical Record", this form is not intended for the release of certain types of medical information, such as HIV, drug/alcohol, mental health, or developmental disabilities.

Is there any information that should NOT be released?   
If yes, please complete the sentence below:
"I do not authorize the following information be released: ."
 
USE OF MEDICAL INFORMATION
What will the medical information be used for? Please complete the sentence below:
"The medical information is to be used only for ."
 
Is there anything specific that you do NOT want the medical information to be used for?
If yes, please complete the sentence below:
"By no means shall the information be used for ."
 
AUTHORIZATION EXPIRATION
Choose an expiration date for the authorization (i.e. the date after which the medical provider is no longer authorized to release the medical information):
 
To clear
the form
If you want to
complete the form later
If the form is
complete;
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