Patient Authorization to Release

In order to provide us with your authorization, please click here for the PDF version, or fill out and submit the form below. Thank you!

I, First * M.I. Last *
(Patient/Parent/Guardian Name)

give permission to the following medical doctors/specialists to release the requested protected health information to Advanced Specialty Anesthesia, LLC

In Regards To:

Patient Name: First * M.I. Last *

Patient Date of Birth: * / MM / DD YYYY

Primary Medical Doctor: *

Facility: *

Address:

Telephone Number: - -

Fax Number: - -

Other Medical Doctor/Specialist:

Facility:

Address:

Telephone Number: - -

Fax Number: - -

Patient/Parent/Guardian Signature (please type your full name to sign this form): *

Date * / MM / DD YYYY

Primary Telephone #: - -

Cell #: - -

Work #: - -

Note: Please complete your request by following the steps presented to you after submitting this form.

PROFESSIONAL DISTINCTIONS

American Association of Nurse Anesthetists

Kansas Association of Nurse Anesthetists

FORMS

PRE-ANESTHESIA HEALTH HISTORY

ADDITIONAL INFORMATION

Surgeon Liability