Release of Information Form

I will release patient health information for treatment, payment, or healthcare operations only after getting consent from the patient and/or parents; for disclosures other than for treatment, payment, or healthcare operations purposes, I will obtain a specific authorization for disclosure from the patient and/or parents; the patient and/or parents may request alternative means of communicating protected health information; the patient and/or parents may request restrictions on disclosures of their protected health information; and I will provide, if requested, a history of most disclosures. In order for me to release your medical record,   Please download the document below.