MEDICAL RECORDS RELEASE

Date:

hereby authorize and request you to release my medical records to

These records can be released to above person (check one):

Via E-Email

at:

Via Fax

at:

The following items and/or dates of service should be released:

Item:

Date:

Add more

I have been informed of Potomac Podiatry Group’s records release protocol. I understand Potomac Podiatry Group, PLLC will not be responsible for any security breach of my personal information.

Patient Name:

Patient Address:

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 Signature:

Date:

Doctor’s Approval:

Date:

PPG Staff Member:

This Records Release expires 90 days after signed. Please allow up to 30 days to receive records.

Electronic Format Fees: $15.00 Administration fee, plus $0.37 per page for first 50 pages and $0.18 per page thereafter.

Your information will be encrypted.