Record Release Forms for Comprehensive Endocrinology PC

Comprehensive Endocrinology, PC

240 W Passaic Street, Suite 14, Maywood NJ 07607

Telephone: (201) 903-0070 Fax: (201) 322-0287

Dr. Ari Geliebter - Dr. Rebecca Geliebter
MEDICAL RECORDS RELEASE

Please complete if you are a new patient
I hereby request protected health information to be released from the medical record of:
Patient Name:
Patient's Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Release Records From:
Send Records to:
Comprehensive Endocrinology, PC Dr. Ari Geliebter - Dr. Rebecca Geliebter 240 W Passaic Street, Suite 14 Maywood, NJ 07607 Phone 201-903-0070 Fax 201-322-0287
This request and authorization applies to: (check appropriate selection)
Treatment, condition or date(s):
I hereby authorize and request the prompt release of medical records without exception, including but not limited to clinical notes, lab tests, pathology reports, radiology reports, messages, prescriptions, consultations and secondary records.
Patient/Guardian Name (Please print clearly):
Signature of Patient/Guardian:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Expiration Date of this Release Form

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

MEDICAL RECORDS RELEASE