Prior to the release of the information approved within this form, signature will need to be obtained by hand. This can be done in person at our office after submitting the form online or via printing, signing, and uploading using the link below. To print the form yourself, you can use the "Print Form" button at the bottom of the form after you have filled in the information. Whether you prefer signature in our office (submit the form on this page) or via an uploaded signed submission, we will contact you directly to verify your submission prior to releasing information. All online submissions are HIPAA compliant.
If you have already signed a completed form, you may upload and submit it electronically here:
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