Medical Records Request Form

REQUESTED

PLEASE FORWARD MY MEDICAL RECORDS AS REQUESTED BELOW TO

Burrows Family Practice, Inc
1377 S. Grand Ave Glendora, CA 91740
Phone: 626-483-3348 Fax: 626-623-7258

NOTE: Hospital and medical office records may include information related to mental health, alcohol/drug, and HIV references. The actual treatment records from mental health and/or alcohol/drug departments, and/or results of HIV tests will not be disclosed unless specifically requested below.

SIGNATURES AND DATES REQUIRED IF ANY OF THE FOLLOWING BOXES ARE CHECKED

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

Duration: This authorization is effective immediately and shall remain in effect for one year from signature of date

Revocation: This authorization may be revoked in writing at any time prior to the release of my information. Written revocation will not affect any action that has taken place before the receipt of the written revocation.

Disclosure: I understand that Burrows Family Practice may not lawfully further use or disclose this health information unless another authorization is obtained from me, or unless disclosure is specifically required or permitted by law.

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

(Patient, parent or guardian signature required) A copy of this authorization is valid as an original only