AUTHORIZATION FOR REQUEST OF MEDICAL RECORDS

To:

I hereby authorize the release of information from the medical record of:

Please Release Information To:

The Healthy Cocoon Practice
27082 Main St. Edwardsburg, MI 49112
Fax: (269) 246-1376 (preferred)

Informed Consent for Release of Confidential Information.

I understand that I may revoke this consent in writing at any time except to the extent action has been taken. I understand that this consent will expire 90 days after the date of my signature unless otherwise specified.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal Privacy Regulations.

Phone: 269-246-1375 │ Fax: 269-246-1376 │ thehealthycocoon.com
Revised 7/2023