Release of Information

Two-Way Authorization to Release Confidential Health Information

In accordance with Federal and State statutory requirements concerning confidentiality of records, I request and give my permission to release/exchange information regarding the following individual:

Patient Name*

Email

Date of Birth*

I hereby authorize the following medical information to be released between: EPIC AND
Skin Rehab
15 E. 7th St.
Grafton, ND 58237

The specific health information to be released/exchanged is (check all that apply):*

Complete Medical Record

Other*

Skin Rehab wants you to be aware of the potential that this information, once forwarded to the other party, could be re-disclosed and no longer protected.

This requested information is to be used for the purpose of

I understand that this consent may be revoked at any time by requesting a Revocation of Two-Way Authorization form. In any event, if not previously revoked, this consent will expire

Patient Signature / Parent signature if under 18*

Date*

Signature of Witness:*

RELEASE OF INFORMATION FORM

Two-Way Authorization to Release Confidential Health Information

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