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State
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Address
Street Address
City
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California
Colorado
Connecticut
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District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
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New York
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Northern Mariana Islands
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Puerto Rico
Rhode Island
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Tennessee
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Utah
U.S. Virgin Islands
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Hawaii
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Virginia
Washington
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State
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Authorization Release
Authorization Release
(Required)
I agree to the terms and conditions.
I authorize the release of Medical Records or any other information deemed necessary in order to process this or any past or future claim on my
behalf, or on behalf of the patient listed above.
I further agree to assign medical or other insurance/employer payment benefits for services provided. I authorize to appeal payment denial or other adverse decisions on my behalf
without further authorization.
I understand I have the right to revoke this authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and submit it to the Medical Records Department.
I agree to pay any coinsurance, deductible or non-covered service so deemed by my insurance carrier.
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Date
MM slash DD slash YYYY
Parent / Legal Guardian / Authorized Person
Date
MM slash DD slash YYYY
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