Medical Records Release Form

Patient Name

DOB

Please release my protected health information to the following person(s):

Name

Address

Phone

Fax

Information to be released

All records

Office visit notes

Physical therapy notes

Labs/x-rays

Surgical notes

Home health/wound care notes

Other

If other, please specify.

By signing this form, I authorize the release of my protected health information as stated above. This authorization is valid for 1 (one) year.

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

Your information will be encrypted.