Auth Release Records From Us - The Heartbeat Clinic

0323 - Auth Release Records From Us

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient’s Full Name:

Date of Birth:

Month

Day

Year

Previous Name:

Social Security #:

Full Name:

Full Address:

Phone (For SMS if appicable):

Fax:

Email:

The request and authorization applies to:

Healthcare information relating to the following treatments, conditions, and/or dates:

All healthcare information

Date ranges (if applicable) From:

To

Other:

I authorize the release of my records to the person(s) listed above.

Yes

No

Patient Signature:

Date:

Witness Signature:

Date:

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED

At The Heartbeat Clinic, we are dedicated to providing expert care for Postural Orthostatic Tachycardia Syndrome (POTS) and related autonomic nervous system disorders.

Disclaimer: The information provided here is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. While we strive to ensure accuracy, the content may not always reflect the latest medical developments. Always consult a qualified healthcare provider for any medical concerns or before making health-related decisions. The Heartbeat Clinic is not liable for any actions taken based on the information provided here. For any changes to the content or recommendations, please email us at [email protected]