AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA "*" indicates required fields PATIENT INFORMATIONFirst Name* Last Name* Email* Phone*Date* MM slash DD slash YYYY Patient ID* AUTHORIZATION TO RELEASE MEDICAL INFORMATIONChoose one* I request and authorize Strive Medical to release/obtain medical information regarding the patient named above to/from the person(s) listed below: Name* Relationship to Patient* This request and authorization applies to:Specification All healthcare information Other (Be specific): OthersName* Relationship to Patient* This request and authorization applies to:People All healthcare information Other (Be specific): OthersName* Relationship to Patient* This request and authorization applies to:Caregivers All healthcare information Other (Be specific): OthersChoose one* I do not authorize the release of my medical information to any person(s) at this time. Patient Signature*Reset to re-sign.Date* MM slash DD slash YYYY The patient listed has the right to cancel or modify the authorization at any time by contacting a Strive Medical representative. If no expiration date is listed, this authorization remains valid until canceled or modified by the patient or their authorized representative. Verify Your IdentityPhoneThis field is for validation purposes and should be left unchanged. Δ
