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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.

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Authorization for
to release protected health information for the purpose of:
Patient Name:
Date of Birth:
Phone Number:
Email:
Provider Name:
Address:
Phone:
Fax:
Ultrasound:
Labs:
Genetic Screening:
Health History:
Pap Smear:
Immunizations:
All Records
Current Pregnancy
Other
I authorize the release of above information 1 year from signature date.
I understand records released herein may include treatment of physical/mental illness, alcohol/dr...
I accept full responsibility for copying fees.
Signature
Date
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