Auth Release Records From Us

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Date of Birth:
I request and authorize: The Heartbeat Clinic – Dr. Amer Suleman to release healthcare information of the patient named above to:
The request and authorization applies to:
All healthcare information
Date ranges (if applicable) From:
To
I authorize the release of my records to the person(s) listed above.
MM slash DD slash YYYY
MM slash DD slash YYYY
THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED