Medical Records Release FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient InformationFull Name *Contact Number *Date of Birth *Email AddressI hereby authorize Neponset Valley Neuropsychology, LLC to (check all that apply)RECEIVE COPIES OF MY MEDICAL RECORD FROM:RELEASE COPIES OF MY NEUROPSYCHOLOGICAL REPORT TO:DISCUSS MY ONGOING EVALUATION WITH:Primary Care Provider or Group PracticeAdditional ProviderAdditional ProviderOtherPhone NumberPhone NumberPhone NumberPhone NumberI hereby authorize Neponset Valley Neuropsychology, LLC to discuss all details related to my evaluation and care with:FamilyPhone NumberOtherPhone Number *I understand that once Neponset Valley Neuropsychology, LLC, discloses my health information to the recipient, Neponset Valley Neuropsychology, LLC, cannot guarantee that the recipient will not disclose my health information to another party. I have read and understand the terms of this authorization. By my signature below, I hereby knowingly and voluntarily authorize Neponset Valley Neuropsychology, LLC, to use or disclose my health information in the manner described above.Signature of Authorized Representative * Clear Signature Date of Signature *Authorized signature valid for 2-years from printed dateSubmit
