Authorization for Access/Release of Information
Tell us your name *
Enter your email *
Enter your Date of Birth *
Phone No *
Address
City
State
ZIP Code
The access of information is for purpose of:
Please Select
Personal use
Continuing care
Legal
Disability
Insurance/Benefits
Others
I hereby authorize HopeQure:
RELEASE information to:
OBTAIN information from:
Name *
Enter email *
Phone No *
Relationship To the User
Address
City
State
ZIP Code
I accept all the term & conditions written below.
I understand that: This is authorization is valid for one year from the date of submission. I understand that after I have agreed to this form, I may change my mind and cancel (revoke) this authorization at any time by contacting HQ for Release of Information services. Cancellation of the authorization will not apply to information that has already been released based on this authorization.The information disclosed in response to this authorization may be subject to re-disclosure by recipient, and will no longer be protected under the terms of this authorization. This authorization is voluntary and my records at HQ are in no way conditioned on whetheror not I approve this authorization and that I may refuse to sign it. The parent or legal guardian must fill this authorization if the patient is a minor (under age 18).
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HopeQure Pvt. Ltd.