Your insurance company may require you to fill out a form like the following if you use your insurance benefits:

RELEASE OF CONFIDENTIAL INFORMATION

Date:

I, the undersigned, grant permission for

to release and share information jointly with Dr. Edward Schmitt of JPS regarding:

Name of Patient


Birth Date


Address


Name(s) of Parent(s) or Legal Guardian(s)


Address if other than above

Description of information to be released: Diagnosis, course and treatment:




To be used for the following purpose and time period: One Calendar Year.

To be released according to subsection S.a.b of Section 748, Public Act 258, or other:




Signed:



Relationship to Patient:



Witness:



Date:



Released to:



Released by:

If you need help understanding what is needed or have questions about a release form, call us at (616) 457-0016 and we will try to help you.

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