Request of Release of Medical Records

Today's Date:

Patient Information:

Patient Name

Date of Birth

Address

City

State

Zip Code

Authorization:

I authorize (Input Practice or Doctor Name below) to release my medical records.

Practice or Doctor Name

Details of Request to Release:

Please release my records to:

(Practice, Doctor, or Individual's Name) If releasing to yourself, please write "self"

Address

City

State

Zip Code

Details of Request- Please check all information you would like released:

Clinic Notes for dates

Clinic Photos

Pathology

Other

If Clinic Notes for dates:

To:

I authorize the release of my medical records:

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 Signature

Date

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 ofthe 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.

FAXED:

TO:

FAX #

Your information will be encrypted.