OCD Anxiety About FAQ

Release of information

Optional. Use when you want the practice to send or receive records with another provider.

Release of information

Patient first name *Patient last name *

I authorize Matthew Brown, DO / this practice to:

Send informationReceive information

Other provider / organization (to/from) *

Their phoneTheir email

Your relationship to patient *Purpose / what may be shared *I understand this authorization is voluntary, may be revoked in writing, and that redisclosure by a recipient who is not a covered provider may not be protected by the same rules.Type full legal name *

Draw your signature *

Draw with finger, mouse, or stylus. This is your electronic signature.

Date *

Submissions are emailed to the practice over encrypted mail for handoff. This site does not keep a clinical chart.

Dr. Matt Brown

Telehealth · IL, KS & MO

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