HEALTHCARE STATUS AUTHORIZATION
I, _______________________________________________(name of patient) hereby give
authorization to East Coast Cardiology, P.A. for the release of information concerning the status
of my healthcare, including but not limited to results of laboratory and radiology tests and to
discuss my plan of treatment with:
_____________________________________
Name of Authorized Individual
______________________
Relationship to Patient
_____ I understand that I may revoke this authorization at any time, with written notice.
_____________________________________
Patient Name (Printed)
_____________________________________
Patient Signature
_____________________
Date
____________________________
Witness