Information Sharing Form

For a patient’s medical records to be released from this facility, the patient must contact the Orthopaedic and Sports Medicine Center’s Medical Records Department for a separate Authorization to Release Medical Information.

Visit Type *

Permission

Permission to Share Your Orthopaedic and Sports Medicine Center Medical Information

Patient's name *

Digital Signature

I attest that the above information is correct and to the best of my knowledge. I have read and understand the entire contents of the form and have had the opportunity to ask questions regarding the information of this form.

Full name *

Date *

Year

Month

Day

If patient representative, what is your relationship to the patient?

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