Medicare Authorization for Release of Health Information
Patient Information
Full Name
Date of Birth
Street Address
City, State, ZIP
Medicare Number
Recipient of Information
Name of Person/Organization to Receive Information
Address
Phone/Fax
Information to be Released
All Health Information
Specific Information (please specify below)
Purpose of Release
Personal Use
Continuity of Care
Legal
Other (specify below)
Authorization Expiration
This authorization will expire on (date or event):
Signature
Signature of Patient or Legal Representative
Date
If Legal Representative, state relationship to patient