Medical Release Form

Patient Name

Date of Birth

SSN

Address

City

State

Zip Code

Phone

Email

INFORMATION REQUESTED FROM

Name

Address

City

State

Zip Code

Phone

Fax

Email

SEND INFORMATION TO

Name

Send by

Mail

Fax

Secure Email

Address

City

State

Zip Code

Phone

Fax

Email

I, hereby grant permission for you to release confidential health information about me, by releasing a copy of my medical record, or a summary or narrative of my protected health information, to the physician/person/facility/entity.

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 Name

Date

Signature

Date

Your information will be encrypted.

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