Medical Records Release Form

Authorization to Release Medical Records/X-Rays

Dear Dr. Deroy/Dr. Duggirala:

This letter will authorize you to provide a copy, summary, or narrative of my medical records (as indicated by the check mark(s) below) or to otherwise release confidential information. At this time I am requesting the following:

Complete record

Records of care from

from

X-Rays (Please note that we do not make copies of x-rays. The original x-rays are the property of the doctor and must be returned within one month. If the films are needed longer, copies of the x-rays should be made at another radiology facility and the originals promptly returned to the doctor. The undersigned takes full responsibility for any unreturned or missing x-rays and a fee may be charged for each missing film.)

(# of films taken)

Records of care concerning the following condition(s).

Other. Specify:

Confer with other person orally about information in my medical record to the following person(s):

Name:

Address

Street, City, State, Zip

The reasons or purposes for this release of information are:

I understand that you will provide this information within 15 business days from receipt of request, and you may charge a fee for preparing and furnishing this information.

The fee is waived because the records are to be used for supporting an application for Disability or other benefits or assistance under Aid to Families with dependent Children, Medicaid, Medicare, Supplemental Security Income, and Federal Old-Age and Survivors Insurance. I have attached a statement, which confirms that such an application or appeal has Been field or is pending.

Name (printed):

DOB:

Signed:

(Patient or person legally authorized to consent on patient's behalf)

Date

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