Authorization of Health Information Form

This is a form for established patients to use when you wish to share specific health information with another person or group apart from typical treatment activities. For example, you may wish to share specific information with a family member, attorney, or other third party person or group.

If you prefer to print this form off and bring it to your appointment instead, please click on one of the forms (English or Spanish), check the box to agree to use electronic records and signatures, click Continue, and select the third button (Download) on the menu above the form. You can then save the blank document as a PDF, print it off, fill it out, and bring it with you to your next appointment.