Authorization to release records | Julie Traynham, D.O.

Please read the complete original form and policies (PDF) before signing. Required fields are marked *. Your entries stay on this page until you submit; they are not saved in your browser.

This authorization is optional. Refusing to authorize disclosure does not affect treatment, payment, enrollment, or eligibility for benefits. Read both pages of the PDF, including the right to revoke, redisclosure risks, limitations, and effective period.

Preview only: online submissions are not yet open. Please use the downloadable forms.

Patient information

Full patient name *Other names used Date of birth *Address *City *State *ZIP code *Phone *Alternate phone Email (optional)

Who may disclose the information?

Person / organization name *Address *City *State *ZIP *Phone Fax

Who may receive and use it?

Person / organization name *Address *City *State *ZIP *Phone Fax

Reason and information to disclose

Choose one: Treatment / continuing medical care; Personal use; Billing / claims; Insurance; Legal purposes; Disability determination; School; Employment; Other *Other reason

Select the records you authorize

Sensitive information: initial only what you authorize

Initials: mental health records (excluding psychotherapy notes) Initials: drug, alcohol, or substance abuse records Initials: genetic information, including genetic test results Initials: HIV/AIDS test results / treatment

Authorization and signature

Specific expiration date (optional) I have read both pages of the authorization. I agree to the specified disclosures and understand the right to revoke, effective time period, and redisclosure terms. *Patient or legally authorized representative: type full name as electronic signature *Signature date *Printed name of representative (if applicable) Representative relationship: parent of minor, guardian, or other Minor’s signature when required for sensitive records Minor signature date I intend my typed name to be my electronic signature. *

Unless you specify an earlier date, the authorization ends at the earliest of death, reaching the age of majority, or withdrawal of permission. You may revoke in writing to the named recipient. Earlier actions taken in reliance on authorization are not affected. Information disclosed may be redisclosed and may no longer be protected by privacy laws. Certain minor records require the minor’s signature. The office will verify authority before acting on a release.

Review your entries before sending. Do not enter payment card details. This form does not schedule an appointment.