Authorization AUTHORIZATION TO RELEASE INFORMATION Patient: Patient Name is required Date of Birth: Please enter valid Date of Birth Released To/From: 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 records Second Opinion Other Clear Patient/Guardian Signature OR Check the checkbox to Upload Signature File Please sign the document. Please upload Valid document (valid extensions: "jpg","png","gif") Date Please enter valid Date 19621 Solar Circle, Ste 202 Parker, CO 80134 (720) 851-1676 hollyslettendmd@comcast.net
