Authorization for the Release of Health Information

  • Printable version of Authorization for the Release of Health Information available here.

    Patient Name:▁▁▁▁▁▁  Phone Number:▁▁▁▁▁▁

    Address:▁▁▁▁▁▁  City:▁▁▁▁▁▁

    State:▁▁▁▁▁▁  Zip code:▁▁▁▁▁▁

    Date of Birth (D.O.B.):▁▁▁▁▁▁

    I hereby authorize,▁▁▁▁▁▁     to release my medical information to▁▁▁▁▁▁

    Middletown Enlarged School District

    223 Wisner Avenue

    Middletown, NY 10940

    ATTN: Medical records:

    Phone number:▁▁▁▁▁▁  Fax number:▁▁▁▁▁▁

    Authorization to Discuss Health Information: 

    By initialing here,▁▁▁▁   I hereby authorize:▁▁▁▁▁▁    to discuss my health information with Middletown School District Health Office.


    TO BE READ AND SIGNED BY PATIENT/GUARDIAN:

    I understand the following:

    I may revoke this authorization at anytime by providing written notice to the school.

    I am signing this authorization freely, under no undue stress from any individual to do so.

    I acknowledge that I have had the opportunity to review this authorization and understand its intent and purpose.

    Signature of Parent/Legal Guardian:▁▁▁▁▁▁ Date:▁▁▁▁▁▁