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.

Question Title

* 1. Patient name:

Question Title

* 2. Phone number:

Question Title

* 3. Email address:

Question Title

* 4. Physician name:

Question Title

* 5. Physician phone:

Question Title

* 6. Physician email:

Question Title

* 7. Type of information to be released:

Release information to:

Question Title

* 8. Name:

Question Title

* 9. Phone number:

Question Title

* 10. Email address:

Question Title

* 11. Fax:

Question Title

* 12. Mailing address:

Question Title

* 13. How should information be released?

Email

Fax

Mail

Question Title

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

I consent

Question Title

* 15. Signature:

Question Title

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

Yes

Question Title

* 17. Date:

Date

Date