Medical Information Release Form (HIPAA Release Form)
Name:________________________________________ Date of Birth___________
Release of Information
I authorize the release of information including the diagnosis, records; examination rendered to
me and claims information. This information may be released to:
Information is NOT to be released to anyone.
The Release of Information will remain in effect until terminated by me in writing.
My cell phone ____________________
If unable to reach me:
You may leave a detailed message
Please leave a message asking me to return your call
The best time to reach me is (day)_______________ between(time)__________
OUCH Urgent Care, LLC 2016