Skip Navigation
Skip Main Content

RELEASE OF INFORMATION FORM

Please complete this field.
Please complete this field.
Please complete this field.

Patient confidentiality is a priority at Prestige Medical Group. This form allows you to specify how and with whom your medical information may be shared. This authorization complies with HIPAA privacy standards.

In the event that I am unable to be reached, I authorize Prestige Medical Group to leave test results, lab results, or other medical information in the following ways (please check all that apply):

Please complete this field.
Please complete this field.

AUTHORIZED RELEASE OF MEDICAL INFORMATION

AUTHORIZED RELEASE OF MEDICAL INFORMATION

Please complete this field.
Please complete this field.
Please enter a 10-digit phone number (numbers only).
Please complete this field.
Please complete this field.
Please enter a 10-digit phone number (numbers only).
Please complete this field.
Please complete this field.
Please enter a 10-digit phone number (numbers only).

This authorization will remain in effect while I am a patient of Prestige Medical Group unless I revoke or modify it in writing. I understand that I may revoke this authorization at any time by providing written notice to the practice, except to the extent action has already been taken based on this authorization.

I acknowledge that I have received or have access to Prestige Medical Group's Notice of Privacy Practices.

Please complete this field.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

E-signature image