Patient

Date of Birth:

name1

Released To/From:

name1name1name1

I request and authorize the above named doctor or health care provider to release my information to the organization, agency or individual named on this request.

PURPOSE(S) OR NEED FOR WHICH INFORMATION IS TO BE USED:

Transfer of recordsSecond OpinionOther

Patient/Guardian Signature OR Signature File(Required)

name1

Date of Birth: