Authorization Form to Release Information

Due to strict privacy regulations, if a patient, for any reason, would need/want our office to discuss any part of his/her financial or medical records with another individual, it would be necessary for this authorization form to be completed and signed by the patient. This is true even for adult children who are covered under a parents’ insurance policy. We do not have the ability to discuss records with patients unless this form is completed by the patient.

Please download and fill-out our Authorization Form to Release Information. After you have completed the form, please make sure to bring it on your first visit to our office. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.