Medical Release of Information

Form 3 of 12

Note: Fields marked with an * indicates required field

Authorization for Verbal Release of Medical Information

This form is authorizing Marwood to share information with the following individuals:

I, as a resident of Marwood Nursing and Rehab (or Legal representative of resident) authorize the release of verbal medical information regarding my treatment, care and updates on my condition to the above individuals.

If signing on the Residents behalf, please provide the Resident's name in the Resident section.

By submitting this Consent Form, please be aware that an electronic signature is as legally binding as a handwritten signature.

This form will be updated annually or upon request by the resident/legal representative.