Serving Hamilton, Butler, Clermont & Warren Counties

Release of Information

Release

Authorize BridgeCare to release your health information to a designated person or organization. All fields marked * are required.

(513) 587-4923 [email protected]

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1Client Information

Full Name*

Date of Birth*

Phone Number

Email Address

Address

2Release Information To

Name of Person / Organization*

Organization / Facility

Phone Number

Address

3Release Details

Information to Release*

Purpose of Release*

Preferred Format

Expiration Date (optional)

4Rights & Acknowledgement

Your Right to Revoke

You have the right to revoke this authorization at any time by submitting a written request to BridgeCare. Revocation will not affect disclosures already made in reliance on this authorization.

I understand and acknowledge my right to revoke this authorization at any time. *

5Guardian / Legal Representative (if applicable)

Guardian / Representative Name

Relationship to Client

6Electronic Signature

By typing your full name below, you authorize BridgeCare to release your health information as described above.

Electronic Signature (Type Full Name)*

Date*

Your submission will be sent securely to our team at [email protected]. A completed PDF copy will be available for download after submission.