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Full Name
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Date of Birth
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Phone Number
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Email Address
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Release of Records Acknowledgment
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To acknowledge, please check the boxes below
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I authorize the disclosure of all protected information relating to my treatment and patient history at More Wellness
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I authorize the disclosure of protected medical information from the office of More Wellness to the office of JoyRich
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I acknowledge and understand that the information being released is solely for the purpose of care continuation
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I authorize the release of All medical records, face sheets, medical history, patient demographics, and appointment informatics
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I authorize the release of all clinical charts, records, and records received by other healthcare providers
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I authorize the release of All billing records and statements
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Patient Signature
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Today's Date
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