Authorization to Release Medical Records

Please correct the errors described below.

I hereby authorize South Bay Allergy & Asthma Associates to release my medical records and data to:

(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

Mode of records release:

Pick up Mail Fax Email

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

Your information will be encrypted.

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

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.

Use this signature or Cancel

Hushmail

Hide