Patient Release of Information Form

 Patient’s Name: ________________________________   Date of Birth: ____________ 

 Previous Name: _________________________   Social Security #: ________________       

I request and authorize ____________________________________________________

to release healthcare information of the patient named above to: 
           

Compassionate Eating, LLC
Dietetic Consulting Services

Amanda Kaster, R.D.
P.O. Box 1125
Lexington, VA  24450 

This request and authorization applies to:

All Healthcare information relating to the following treatment, condition or dates, including labs:

            _________________________________________________________________________

Only lab information related to the following treatment, condition or dates:

            _________________________________________________________________________

           

Other: ___________________________________________________________________

(Yes)  -  (No)  I authorize the release of any records regarding drug, alcohol, or mental health treatment to Compassionate Eating, LLC.

Patients Signature: ______________________________  Date Signed: ______________

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.