Authorization to Share Information In order to comply with federal regulations regarding your privacy in our office, we ask that you complete the following questions: Patient InformationPatient Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Leave appointment and billing messages on/with:* On home phone? On cell phone? On office voice mail? With another person? Send via email? Leave medical information messages on/with:* On home phone? On cell phone? On office voice mail? With another person? Send via email? If you answered YES to allowing us to discuss your appointment, billing, and/or medical information with another person, please list their name(s), relationship(s), and phone number below:Name* First Last Relationship*Phone*Cell PhoneWould you like to add another person?* Yes No Name* First Last Relationship*Phone*Cell PhoneAdditional HIPAA Contact Instructions:Patient or Legal Representative* First Last If Legal Representative, please indicate relationship:Electronic Signature (E-Signature) AgreementBy selecting the "I Accept" button, you are signing this Release of Records electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Release of Records. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to sign this Release of Records for all persons listed on this form.*I AcceptElectronic Signature:Name* First Last Today's Date* Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.