Medical Release Form

NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information.

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1. Patient name:

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2. Phone number:

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3. Email address:

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4. Physician name:

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5. Physician phone:

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6. Physician email:

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7. Type of information to be released:

Release information to:

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8. Name:

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9. Phone number:

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10. Email address:

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11. Fax:

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12. Mailing address:

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13. How should information be released?

Email

Fax

Mail

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14. I consent to the release of my medical information to the individual named above:

I consent

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15. Signature:

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16. I acknowledge that by entering my name above I am providing a digital signature.

Yes

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17. Date:

Date

Date