Medical Release Form

North Shore Nutrition Consultants, LLC accepts the following insurance plans:

View our HIPPA Notice

Authorization to Obtain/Release Confidential Medical Information

Patient Details

I authorize North Shore Nutrition Consultants, LLC to share my progress and health care information with medical professionals and the following individuals.


Primary Care Physician


Referring Physician/NP/PA


Specialist (Cardiologist, Endocrinologist, Allergist, etc.)


Mental Health Therapist


Other

I understand that my records and treatment is confidential. They will not be disclosed without my consent. I understand I may revoke this consent at any time.