Patient Consent and Release Form

HIPAA Compliant Authorization for Release of Patient Information and Appointment of Authorized Representative

Patient Name(Required)
Patient Consent(Required)
Patient Consent:(Required)
Consent(Required)

Expiration: This Authorization will expire the earlier of one year from the date entered below OR upon conclusion of my appeal process and related services.

Revocation: I understand that I may revoke (withdraw) this Authorization at any time by notifying GYNESONICS, in writing, to [email protected] However, I understand that if I revoke my Authorization, it will not affect any of My Information shared with GYNESONICS before my revocation.

Physician Name(Required)
Physician Address(Required)
APPOINTMENT OF AUTHORIZED REPRESENTATIVE:(Required)
Consent(Required)
Consent(Required)
Patient or Legal Representative Name(Required)