Send My Medical Records to Another Doctor or Office

Patient Information

Name

Date of Birth

Phone Number

Send my records to this office:

Name

Address

City

State

ZIP

How to share Medical Records/Delivery method:

Fax Email

Fax Number:

Email address

Which Medical Records?

What date range should be included?

Purpose

I authorize the release of my health information for the following specific purpose:

I authorize PrimeCare of Coral Gables to release confidential health information about me as instructed above.

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:

Date

Your information will be encrypted.