Release of Medical Records

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Patient Name:

Date of Birth:

SSN:

PHONE#:

I authorize the release of medical records as follows:

FROM / TO (Select One)

Phone:

Fax:

Requested Information:

(e.g. Office Visit Notes, Allergy Testing, Entire Chart, Etc.)

Dates of Service:

This authorization expires 30 days from the date of the signature below. I understand that I may revoke this authorization at any time with a written, signed and dated notice. However, disclosures made prior to the revocation will not be affected. A copy of this authorization may be used in place of the original with the same effectiveness. I understand there may be fees associated with making copies and mailing these records.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Patient Representative

Date:

Print Name

Relationship to Patient

Your information will be encrypted.