I,
    First Name:

    Last Name:

    Social Security Number:

    Medicare/Insurance ID#:

    By my signature below I give my permission for the receiver of this document to share my medical records/information with Creative Prosthetics & Orthotics, LLC. The information will be used only for sharing with other health care providers as needed, insurance processing or review, legal reasons or other reason(s) specified below:
    Other:

    This medical release document will be enforce from the date entered below and will terminate upon receipt of written notification.

    Legal Guardian name:

    Relationship to Patient:

    three + 1 =