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Apple Android Windows

Midwife Medical Records Release Mobile App

Use the Midwife Medical Records Release mobile app to allow patients authorize and to give permission to share medical information protected health information. The app allows the patient to state the purpose of sharing the health information. The authorization release is good for one year from the date of signature. Records released herein may include treatment of physical/mental illness, alcohol/drug abuse, and sensitive medical history.

GoCanvas has a collection of apps developed for Midwives and Doulas. They are all Free with your GoCanvas Subscription. Check them out in our Application Store!

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

Want to learn more about GoCanvas?

Request a Demo

Take a peek inside the Midwife Medical Records Release Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Authorization for

  • Ico textbox

    to release protected health information for the purpose of:

  • Ico textbox

    Patient Name:

  • Ico date

    Date of Birth:

  • Ico textbox

    Phone Number:

  • Ico textbox

    Email:

  • Ico textbox

    Provider Name:

  • Ico multiline

    Address:

  • Ico textbox

    Phone:

  • Ico textbox

    Fax:

  • Ico checkbox

    Ultrasound:

  • Ico checkbox

    Labs:

  • Ico checkbox

    Genetic Screening:

  • Ico checkbox

    Health History:

  • Ico checkbox

    Pap Smear:

  • Ico checkbox

    Immunizations:

  • Ico checkbox

    All Records

  • Ico checkbox

    Current Pregnancy

  • Ico textbox

    Other

  • Ico statictext

    I authorize the release of above information 1 year from signature date.

  • Ico statictext

    I understand records released herein may include treatment of physical/mental illness, alcohol/dr...

  • Ico statictext

    I accept full responsibility for copying fees.

  • Ico signature

    Signature

  • Ico date

    Date

  • ...and More!

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