Ohio Holistic Healthcare, LLC

570 N Leavitt Rd

Amherst, OH  44001

440-340-1970 (phone)

440-370-3026 (fax)

ohhc2018@gmail.com

www.ohioholistichealthcare.com

PATIENT AUTHORIZATION TO RELEASE MEDICAL RECORDS

*Complete & RETURN to our office via email, fax, mail or drop off.  We must have your records before we can schedule a Medical Cannabis appointment.  All other appointments, it may not be needed right away.

PATIENT NAME:______________________________________________________

D.O.B.:_______________________                                 SS#:***-**-______________

PHONE:______________________                            EMAIL:________________

ADDRESS:__________________________________________________________

                   __________________________________________________________

FACILITY/PHYSICIAN/PRACTICE FROM WHICH RECORDS BEING REQUESTED:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

DATES OF SERVICE TO RELEASE:______________________________________

SPECIFIC REPORTS TO BE RELEASED:__________________________________

MODALITY BY WHICH INFORMATION IS TO BE DISCLOSED:

MAIL                EMAIL                PICK UP IN PERSON                OTHER

______________________________     _______________________

Signature of Patient/Patient’s Legal Representative                Date

____________________________________________________          ________________________________________

Relationship to Patient                                        Date