Medical Records Release Request Form

I HEREBY AUTHORIZE AND REQUEST YOU TO RELEASE MY MEDICAL RECORDS TO:

DR. AIMEE ALTSCHUL-LATZMAN

ADDRESS:
140 SHERMAN STREET, 3RD FL
FAIRFIELD, CT 06824
TELEPHONE: (203)955-1461
FAX: (203) 955-1464

PLEASE INCLUDE INITIAL CONSULT WITH PHYSICAL EXAM, ALL ALLERGY PROGRESS NOTES, ALL ENVIRONMENTAL, FOOD, VENOM, AND DRUG SKIN TEST RESULTS, SPIROMETRY TESTS, LABORATORY TESTING, AND UP TP DATE IMMUNOTHERAPY RECORDS.

I AM AN (ALLERGY SHOT) IMMUNOTHERAPY PATIENT. PLEASE INCLUDE MY UP TO DATE IMMUNOTHERAPY DOSE RECORDS.

PATIENT NAME

FIRST NAME, LAST NAME

DATE OF BIRTH

ADDRESS

SIGNATURE

DATE

RELATIONSHIP TO PATIENT

CHECK HERE IF I WILL BE PICKING UP MY MEDICAL RECORDS IN PERSON

PLEASE FAX OR MAIL RECORDS TO DR. AIMEE ALTSCHUL-LATZMAN FAX # OR MALING ADDRESS ABOVE.

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