Release of Information
AUTHORIZATION FOR USE AND DISCLOSURE OF MEDICAL INFORMATION
This authorization allows the healthcare provider(s) named below to release confidential medical information and records regarding my medical history, illness or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, correspondence and/or medical records including those from my other health care providers that the above named health care provider may hold, by means of mail, fax, or other electronic methods.

Note: Information and records regarding treatment of minors, HIV, psychiatric/mental health conditions, or alcohol/substance abuse have special rules that require specific authorization.
I authorize Congruity Healthcare PC, Ross Palmer MD, and their designates to *
***The following information should be for the party to send/receive information from, NOT your information.***
Name (Example: if you want Dr. Palmer to be able to speak with Dr. Smith, put Dr. Smith's name and information here.) *
Address *
City *
State *
Zip Code *
Phone Number (###-###-####) *
Fax Number (###-###-####) *
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