Consent to release medical information FROM Weigel

Please fill-in the form below. All fields are required.

1) PATIENT INFORMATION
 Input
Patient Name:
Patient Last Name:
Patient Middle:
Maiden Name (if applicable):
Date of Birth:
Banner ID: Open User Lookup
Phone Number:
Email:
RELEASE RECORDS FROM:
Weigel Health Center
Buffalo State University
1300 Elmwood Ave.
Buffalo, NY 14222.
2) RELEASE INFORMATION TO:
  
Provider Name or Office
Street:
City:
State:
Zip Code:
Phone Number:
Fax Number:
3) MEDICAL INFORMATION TO BE SENT:
Please check all that apply.
Record of care from (dates): to
Copy of last annual GYN
Immunization Records
Physical Exam:
Pap Smear
GC and Chlamydia tests:
Copy of any abnormal tests:
Summary of treatment for:
Other (please specify):
Electronic Signature Disclaimer for Release of Medical Information
By electronically signing this authorization, I acknowledge and agree to the following:
1. Voluntary Authorization: I authorize the release of my medical information to the designated office as specified in this request.
2. Electronic Signature Validity: I understand that my electronic signature carries the same legal effect as a handwritten signature and confirms my intent to authorize the release of my medical information.
3. Scope of Information: I authorize the release of the specified medical records, which may include sensitive information.
By signing below, I confirm that I have read, understand, and agree to the terms of this authorization.
Electronic Signature:
Date: