Records Release PLEASE READ
To save our patients time, we have created this online release form for your convenience.
By completing this release on line, and sending it to us via the web, your agree to the following:
I authorize Elite Primary Care to release or obtain my medical information. I also give Elite Primary Care permission to speak with any physician at any time in reference to me or my medical condition.
THIS INFORMATION MAY BE DISCLOSED AND USED BY THE FOLLOWING INDIVIDUAL OR ORGANIZATION:
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to Elite Primary Care. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer the right to contest a claim under my policy.
I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the term and conditions of this authorization.
If you agree to the above, please complete the form details on this page and submit.