Authorization for Medical Records Request

Please correct the errors described below.

I hereby authorize

to release my medical records and data to South Bay Allergy & Asthma Associates.

Records requested from:

(Physician) Name

(Physician Phone Number)

(Physician Fax Number)

I am requesting the following records to be sent:

Complete medical record

Progress/visit notes

CT scan and/or X-ray results

Allergy skin test results

Serum formula for immunotherapy

Current immunotherapy schedule

Other

If other, please specify

Patient Name

Date of Birth

Phone Number

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.

Patient/Guardian Signature

Date

Internal Use Only

Completed by

Date

Request sent via

Fax Email Mail

Your information will be encrypted.

Electronic signature

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I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

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