Release of Medical Information

Release of Medical Information
Name*
First Last
Email*
I Authorize*

Name of Doctor/Therapist or Pain Specialist above and their Address Below
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Doctor/Therapist or Pain Specialist Phone Number*
Doctor/Therapist or Pain Specialist Fax Number*
Doctor/Therapist or Pain Specialist Email
To Release My Health Information to the Office of:

Portland Ketamine Clinic
Dr. Enrique Abreu, Dr. Danyi

Phone: (503) 207-4992
Fax: (503) 961-1859
Description of Information to be Disclosed*
- All of my health information that the provider has in his or her possession including information relating to any medical history, mental or physical condition and any treatment received by me.
- Only the following records or types of health information.
If Checked Option 2: List Records or Types of Health Information to be Disclosed

Type NA if not applicable
List Any Other Doctors/Therapists or Pain Specialists You Would Like to Authorize to Release Health Information
Signature Agreement of Patient or Legally Responsible Party*
Signature
Date*
MM slash DD slash YYYY
If Legal Representative, Relationship to the Patient
Is There Anything Else You Would Like the Doctor to Know?
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Phone
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