Request for Release of Medical Records

Date:

To:

Address:

I hereby authorize you to release to GASTROENTEROLOGY & NUTRITION CLINICS, P.C. all information and records in your keeping of any and all examinations, procedures, and treatments rendered to me during the following period:

From:

To:

Full Name of Patient:

SSN or Date of Birth:

Signature or Patient or Responsible Party:

Date:

Name of Person Giving Consent:

Relationship to Patient:

Witness:

Date:

Is the Patient unable to Sign?

Yes

If yes, please provide the reason:

Your information will be encrypted.