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Release/Authorization of Disclosure of Health Information
Release of Information From (Sender):
Relase of Information To (Recipient):
Disclosure of Medical/Billing Information is limited to the Following (check all that apply)*:
Approved Method of Delivery
This information is to be released for the purpose of (check all that apply):

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.

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