Permission To Release Medical Records

Patient Name:

Date of Birth:

From:

Name:

Address:

City:

State:

Zip:

To:

Name:

Address:

City:

State:

Zip:

Please circle requested records:

Chart Notes X-rays (will be copied onto a disc)

The following date of service:

From:

Through:

This request will expire in 6 months from the signed date or:

Specific Expiration Date

Print Name:

Relationship if signed by representative:

Signature

Date:

Your information will be encrypted.

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