Release of Medical Information Patient Name:(Required)Date of Birth(Required) MM slash DD slash YYYY Phone(Required)Email(Required) Above listed patient authorizes the following healthcare facility to make record disclosure:Facility Name: Ryze HRT LLCFacility Phone: 910-218-0978Type of Information to disclose(Required) Lab Results Referral Medical/Functional Forms Other Prescription History The purpose of disclosure(Required) Referral Medical/Functional Forms Other RESTRICTIONS: Only medical records originated through this healthcare facility will be copied unless otherwise requestedThis information may be disclosed and used by the following individual/organization(Required)Patient Name(Required)Date(Required) MM slash DD slash YYYY Signature(Required)CAPTCHA
