Request of Release of Medical Records

Date Requested:

Date Sent:

TO:

Address:

City:

State:

Zip Code:

I hereby request that my medical records be released to:

Physician's Name:

Address:

City:

State:

Zip Code:

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’s Name:

Address:

City:

State:

Zip Code:

Birth date:

Social Security Number:

CONFIDENTIALITY NOTICE: The documents accompanying this transmission contain confidential information belonging to the sender that is legally privileged and protected. This information is intended only for the use of the individual or entity to where it is directed.

If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of these documents is strictly prohibited.

IF YOU RECEIVED THIS TELECOPY IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY AND ARRANGE A RETURN OF THESE DOCUMENTS.

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