Request for the Release of Patient’s Medical Records

Print Patient's Full Name:

Date of Birth:

Phone #:

Street Address:

City:

State:

Zip:

I authorize to disclose/release information:

TO FROM

Physician’s Name or Medical Group:

Address:

City:

State:

Zip:

Phone #:

Fax #:

Requested Records:

Purpose of disclosure:

Moved/changed address

Legal investigation

Insurance

Continued care

Referral to Specialist

Patient Request

Other

Date(s) of Service:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Responsible Party:

Date:

Printed Name:

Your information will be encrypted.