Authorization to Furnish Medical Information

Date: ________________________

Patient: _________________________________

 (Please Print)

SSN: ________/__________/___________

I __________________________ authorize Acadiana Physical Therapy to make copies of my records, relative to the diagnosis, treatment and prognosis of my injuries and my condition. A photocopy of this authorization shall be considered as effective and valid as the original.

Patient Signature: _____________________________________

Date: _______________________________________________