Authorization to Release Information Form

AUTHORIZATION TO RELEASE INFORMATION

Name:_________________________________
ID No.________________________________
Date of Birth:________________________
SSN:__________________________________
Phone:________________________________
Email:________________________________
Address:______________________________

I, {Name}, hereby authorize {Party Name} to {release/obtain} the following information:

{Medical, service, dental, etc. information}

I authorize this information to be used for the sole purpose of {description of purpose, and specific restrictions if necessary}.

I understand that this information will be used for {purpose}. I understand that I can revoke my consent through writing at any time.

_________________________________________
(Authorizer's Signature)

_________________________________________
(Date)

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