AUTHORIZATION FOR RELEASE OF RECORDS

I hereby authorize Becker ENT to transfer, release, or obtain information on the following:
Please select the provider you are scheduled to see*
(Name of Patient)*
(Date of Birth)*
Date Format: MM slash DD slash YYYY
(Social Security Number)
(Telephone Number)*
Email*
Address*
Street Address City State ZIP Code
OBTAIN FROM:
(Institution/Physician)
(Attention)
Address
Street Address City State ZIP Code
Phone
Fax
SEND OR FAX TO:
(Institution/Physician)
(Attention)
Address
Street Address City State ZIP Code
Phone
Fax
PLEASE CHECK SPECIFIC INFORMATION REQUESTED*
- ALL RECORDS
- LABORATORY
- X-RAY REPORT
- CT REPORT
- MRI REPORT
- PROGRESS NOTES
- OPERATIVE NOTES
- AUDIOGRAM
- ALLERGY TESTING
- SLEEP STUDY/CPAP
- OTHER (PLEASE SPECIFY)
OTHER (PLEASE SPECIFY)*
(SIGNATURE OF PATIENT OR PARENT/LEGAL REPRESENTATIVE)*
(RELATIONSHIP TO PATIENT)*
(DATE)*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.