AUTHORIZATION TO RELEASE HEALTHCARE INFORMATIONPatient’s Full Name: Date of Birth: Month Day Year Previous Name: Social Security #: I request and authorize: The Heartbeat Clinic – Dr. Amer Suleman to release healthcare information of the patient named above to: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 informationDate ranges (if applicable) From:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ToMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Other: I authorize the release of my records to the person(s) listed above. Yes No Patient Signature: Reset signature Signature locked. Reset to sign again Date: MM slash DD slash YYYY Witness Signature: Reset signature Signature locked. Reset to sign again Date: MM slash DD slash YYYY THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED Δ
