Record Release Form

Date:

Patient Name:

Date of Birth:

Requesting Records From

Doctor / Hospital:

Address:

Phone:

Fax:

I hereby authorize and request that you release medical records to:

Doctor / Hospital

Address:

Phone:

Fax:

The complete Medical Records in your possession concerning my illness and/or treatment during the period of:

To:

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 / Relative Signature:

Your information will be encrypted.