Release of Medical Records
Please only fill out if you need your records sent to your new Doctors office
Date
*
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Month
-
Day
Year
Date
Regarding:
*
To Whom it May Concern
I hereby authorize to release all medical information concerning the care, condition and treatment of my case. The information is to be sent to the following:
Name of Physician or Facility
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Fax Number
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Area Code
Phone Number
Patient Name
*
First Name
Last Name
Patient Signature
*
Date of Patient Signature
*
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Month
-
Day
Year
Date
Patient Phone Number
*
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Area Code
Phone Number
Patient Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Birth Date
*
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Month
-
Day
Year
Date
Submit
Should be Empty: