CHA Medical Information Release Form Medical Information Release Form Patient Information: Full Name: Date of Birth Membership # Release of Information I hereby authorize Christian Health Aid to disclose the selected information: Please choose one: * All Medical Information (including g assessment, diagnosis, & treatment of patient’s condition, appointment concerns, Doctor’s notes, and medical records), and Billing information. Billing information only Section Please list the name and relationship of the people you wish to have this access. Access Name 1 * Relationship 1 Access Name 2 Relationship 2 Access Name 3 Relationship 3 Access Name 4 Relationship 4 Section This Release of Information will remain in effect until terminated by me in writing. Signed signature keyboard Clear (Patient or Responsible Party) If you are human, leave this field blank. Submit