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 any of the following information: Any medical information including assessment, diagnosis, treatment of patient’s condition, billing issues, appointment concerns, and medical records. 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 Clear (Patient or Responsible Party) Submit