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Release of Information / Records Request

Patient Name Date of Birth

Release Records From

Release Records To

Name / Clinic Address

Phone Fax

Records Requested

I authorize the release of the records described above for continuity of care and treatment coordination.

Patient Signature

Signature

Date

Signature is only held in this browser view. Closing or refreshing the page clears it unless printed/saved.

Search for

Near

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Relistor

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Andrew Saurin

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Telehealth Visit

HPI consent to telehealth visit.

99213 code used

Note: Physical Exam left for reference only.

Syringeable Snippet

Patient presents via telehealth for visit. Patient consents/agrees to a telehealth visit.

Andrew Saurin

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