Authorization to Release Healthcare Information
Patient’s Name: ____________________________ DOB: _____________________________
Previous Name:____________________________ Social Security #: ___________________
I request and authorize Prosthetic Orthotic Specialists of Monroe to release healthcare information of
the patient named above to:
(Dr. who referred you to our office)
Name___________________________________________________________________________
Address_________________________________________________________________________
(if you are diabetic please also list the doctor treating your diabetes)
Name___________________________________________________________________________
Address_________________________________________________________________________
I also request and authorize the above named person(s) or organization to release healthcare
information of the above named patient to Prosthetic Orthotic Specialists of Monroe.
This request authorization applies to:
⃝ Healthcare information relating to the following treatment, condition, or
dates:__________________________________________________________________
⃝ All healthcare information
⃝ Other:__________________________________________________________________
If we are unable to speak to you by phone, may we leave a message on your voicemail? Yes
May we leave a message with the person answering the phone?
Yes
No
If yes, I authorize messages to be taken by:
_____________________________________ _______________________________________
Please print name/s
Relationship
Patient Signature: ________________________________ Date:_______________________
*THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED*
No