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Your Name*Email Address*Phone Number*Select a Location*Contact ReasonSubjectMessage*Sending ToSending From Page

Release/Authorization of Disclosure of Health Information
*First Name
*Last Name
Today's Date
*Date of Birth
*Cell Phone
*Email Address
Home Address
City
State
Zip Code
Release of Information From (Sender):
*Your Primary Viverant Location
Relase of Information To (Recipient):
*Recipient Name
Recipient Address
*Recipient Email
*Recipient Contact Number
Disclosure of Medical/Billing Information is limited to the Following (check all that apply)*:
Approved Method of Delivery
*Approved Method of Delivery Details
This information is to be released for the purpose of (check all that apply):


Other purpose for information release (if specified)

I understand by signing this form that I am requesting information to be sent/released to the third party I have indicated above. I understand I may revoke this authorization at any time with written notification. I realize that Viverant cannot prevent re-disclosure of records as a result of this request; therefore, Viverant is released from any and all liability resulting from re-disclosure. I have read and understand my rights.

Authorization expiration date

(expires one year from date above unless earlier date indicated)

*Patient/Legal Representative Signature*Patient/Legal Representative Printed Name

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Your Name*Email Address*Phone Number*Select a Location*Contact ReasonSubjectMessage*Sending ToSending From Page