Authorization for Release of Medical Records to Margolin, Keinarth & Alberda, M.D.

Please correct the errors described below.

Patient Information:

Name:

DOB:

Phone:

Address:

City:

State:

Zip Code:

Please select:

Mail Copies Fax Copies

Purpose of Request:

Continuing Care Personal Transfer Other

If Other, please explain:

Release Information from:

Name/Facility:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Information to be Released:

Please provide a 2-year abstract (includes 5 years of labs, radiology, and diagnostics)

Please provide my entire record for dates:

From:

To:

Please provide only the following records:

Progress/Consult Note

Labs

Radiology

Pathology

Add date

I (please select)

DO DO NOT

want Psychiatric Treatment Notes released

I (please select)

DO DO NOT

want information about my Mental Health released

I (please select)

DO DO NOT

want information about Alcohol and/or Substance Abuse released

I (please select)

DO DO NOT

want information about HIV Tests & Related Information released

I (please select)

DO DO NOT

want information about

released

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:

Parent/Legally Recognized Representative Name:

Witness Name:

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