Release of Medical Information to Another Facility Form

Last Name *

First Name *

MI *

Date of Birth *

Address *

Address

Line 1

Line 2 (optional)

City

State/Province

Zip/Postal

Phone # *

Email *

Authorize Records Released To: *

Authorize Records Released To:

Name

Address

City

State/Province

Zip/Postal

Records To Be Released From Dates Of Service *

From Date

To: *

To Date

Records To Be Released: *

Purpose For Release: *

Release Records From: *

Digital Signature of Patient *

IF RECORDS ARE 40 OR MORE PAGES, THERE WILL BE A CHARGE OF $15.00 PLUS POSTAGE. PREPAYMENT IS REQUIRED.

If signed by person other than patient, state relationship:

Date

This authorization will expire one year from signature date. I understand that I may revoke this authorization at any time by providing my written revocation. This release is executed in conformity with Wis. Stats. §§146.81-83, 51.30, 252.15 and 102.13.