Authorization for Release of Nutrition and Medical Records

Patient Information

Name: _________________________________ Date of Birth: //___ Address: _______________________________ Phone: ()________ Email: _________________________________

Records to be Released From

Practice/Provider Name: __________________ Address: _______________________________ Phone: ()________ Fax: ()________

Records to be Released To

Practice/Provider Name: __________________ Address: _______________________________ Phone: ()________ Fax: ()________

Information to be Released (Check all that apply)

• Complete nutrition records
• Dietary assessments and plans
• Anthropometric measurements
• Laboratory results
• Progress notes
• Consultation reports
• Other (specify): ____________________

Date Range

From: //___ To: //___

Purpose of Release

• Continuing care
• Personal records
• Insurance
• Legal purposes
• Other (specify): ____________________

Authorization

I understand that:

• This authorization is valid for 12 months unless revoked in writing
• I may refuse to sign this authorization
• I may revoke this authorization at any time in writing
• The revocation will not apply to information already released
• Treatment is not conditioned upon signing this authorization
• Information disclosed may be subject to redisclosure by the recipient

Signature: _______________________________ Date: //___ Relationship to Patient (if not self): _____________________

For Office Use Only

Request received by: _____________ Date: //___ Request processed by: ___________ Date: //___