Authorization for Treatment and Medical Record Release

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Authorization for Treatment

I, the undersigned, hereby authorize [Practice Name] and its endocrinology healthcare providers to provide medical evaluation, testing, and treatment. I understand that:

• The practice will explain recommended treatments and alternatives
• I have the right to refuse any procedures or treatments
• No guarantees have been made regarding treatment outcomes
• I am responsible for following treatment recommendations

Specific Authorizations

• Blood glucose monitoring and management
• Hormone level testing and treatment
• Thyroid function evaluation and care
• Diabetes education and management
• Medication administration and adjustments

Release of Medical Information

I authorize the release of medical information necessary to:

• Process insurance claims
• Coordinate care with other healthcare providers
• Comply with audit requests from insurance carriers
• Support prescription management and laboratory services

Financial Responsibility

I understand that I am financially responsible for all charges, regardless of insurance coverage. I authorize my insurance benefits to be paid directly to [Practice Name].

Signature

Patient/Guardian Signature: _________________ Date: _________ Witness Signature: ________________________ Date: _________

Practice Information

[Practice Name] [Address] [Phone] [License/Certification Numbers]