HIPPA FORM Release of Information I authorize the release of information including the diagnosis, records, examination rendered to me and claims information. This information may be released to: If you are unable to reach me, please: Leave a detailed message Leave a message asking me to return your call Text me requesting me to call back By submitting this, I am confirming that this represents my authorization and electronic signature so that everything submitted is accurate and these are my desires moving forward. -Choose-YesNo
