Patient Name

Date of Birth (mm/dd/yyyy)

Address

City

State StateAlabamaAlaskaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Phone (XXX-XXX-XXXX)

Email Address (name@website.com)

Completed forms to be delivered to: Completed forms to be delivered to: Patient (to address above)

Third Party

Claim #

Fax # (XXX-XXX-XXXX)

Address

City

State StateAlabamaAlaskaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Anticipated date to leave work (mm/dd/yyyy)

Anticipated date to return to work (mm/dd/yyyy)

Anticipated Date of Healthcare Event (e.g., surgery, delivery, etc.) (mm/dd/yyyy)

Name of clinic

Please indicate your acceptance by checking the following boxes Please indicate your acceptance by checking the following boxes I understand that my treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.

I understand that I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation.

I understand that if the requestor or receiver is not a health plan or health care provider; the released information may no longer be protected by federal privacy regulations and may be disclosed.

I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it.

I understand that I can request a copy of this form after I sign and date it.

Electronic Signature of Patient or Legally Authorized Representative

Date Signed (mm/dd/yyyy)