Medical Release Form | At Home Health

AUTHORIZATION FOR RELEASE OF INFORMATION / RECORD

Client's First name

Client's Last name

Medical Record No:

Start of Care Date:

Date of Birth

Month

Day

Year

1. I hereby authorize At Home Health, LLC to release to:

2. Information to be released:

3. The above information is released for the following purpose and the purpose only. Any other use is forbidden.

I also understand that I may revoke this authorization at any time.

5. This authorization will expire sixty (60) days from the date of my signature or as otherwise specified by date, event or condition as follows:

6. With respect to any mental health information that may be contained in the client’s clinical records, I hereby waive my/his/her right to the privileges of confidentiality.

Client Signature or Legal Representative

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Signature Date

Month

Day

Year

Relationship to Patient

Witness Signature

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Witness Name/Title