Medical Records Release Authorization (To HIP)

Please correct the errors described below.

Please send:

*** The previous office may charge fees for copying medical records, so please contact them with any questions/concerns.

Add Child

(If over 18 years of age, patient must sign)

** PLEASE NOTE: This authorization will expire 90 days after the date identified above. In the event that you need to cancel this authorization, the cancelation must be received in writing. If the records have already been sent to the organization listed on this request, a separate written revocation must be sent to those persons.

NOTE: When this form is completed, please mail or fax it to your previous doctor in order to have the records copied and sent to our office. THANKS!

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