Information Release Form

JEFFERSON ORTHOPEDIC CLINIC
920 AVENUE B
MARRERO, LA 70072

To protect your privacy, we need you to provide us a list of family / friends that we can release your Medical information to. If you do not want any information released to anyone please check off below at selection #3 and sign below,

I give Jefferson Orthopedic Clinic permission to discuss and / or release all confidential information of any kind, (personal, medical, financial — anything & everything) that they have in their possession regarding myself to the following people:

Patient Last Name

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Patient First Name

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Middle Name:

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Relationship:

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Telephone:

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First Name:

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Middle Name:

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Last Name:

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Relationship:

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Telephone:

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I do not wish to release my medical information to family or friends:

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Patient First Name:

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Middle Name:

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Last Name:

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Date of Birth:

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Patient’s Signature:

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Today's Date

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