Release of Information Form

Home Release of Information Form

We take confidentiality seriously. Patients have the option to electronically request release of information (ROI) to and from other providers (e.g. therapists, primary care doctors, specialists) or loved ones.

Please fill out the form below and electronically sign to allow us permission to share medical information.

Please click on the “Submit” button when complete.

Your Name

Date of Birth

Best Phone Number to Reach You

Other Provider/Loved One: Information #1 (Name, Fax, Phone)

Other Provider/Loved One: Information #2 (Name, Fax, Phone)

Name of doctor at Couch & Cardigan

I am allowing the following information to be shared between medical providers

Further comments/instructions (optional. e.g. release my medical records; this is my therapist; this is my spouse) )

Electronic Signature (Please type in first and last name here)

Today's Date

Please check all of the following:

I am electronically signing the request for Release of Information (ROI) between Couch & Cardigan and the provider(s) above.

I understand that the ROI can be rescinded at any time with a written request.

Release of Information Form

Please check all of the following:

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