Patient Information

To/From

Period of healthcare covered


I give special permission to release any information regarding:


Purpose of Disclosure

I have reviewed and I understand this Authorization. I also understand that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer be protected under federal law.

© 2019 Black River Health. All rights reserved.
Website Development & Hosting by BlueTone Media

 
Black River Health Logo