Patient Forms Authorization to Release Medical Records First and Last Name* Date of Birth*I authorize WPH to communicate with/release my medical records to (via telephone, letter, or fax) the following persons (e.g., Primary Care Physician, family members): 1. Name of person and your relationship to that person* 2. Name of person and your relationship to that person 3. Name of person and your relationship to that person 4. Name of person and your relationship to that person Signature* Date* reCAPTCHASubmitReset
