Release of Information Form

Release of Information Form

Release of Health Form

Patient First Name:
Patient Last Name:
Date of Birth:
Last 4 of SSN:
Address:
Phone Number:

I do hereby request to receive a copy of medical record information by (please select one):
If Fax, Email, other mailing address, or special instructions, please specify below or state not applicable:

The record being requested is of:
If other, please specify:

Date(s) of service:
Specific Information Requested:
If other, please specify:

Reason for Request:
If other, please specify:

The patient gives Wayne County Hospital, Inc permission to release information through verbal request. I attest that I have witnessed the patient’s verbal request.
Thank you for choosing Wayne County Hospital for all your healthcare needs.

Thank you for choosing Wayne County Hospital for all your healthcare needs.

You may now pay your bill online using the button below.

Pay