Authorization to Obtain Healthcare Information

Authorization to Obtain Healthcare Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Format: (000) 000-0000.
Patient Address

Street Address

Street Address Line 2

CityState

Zip Code
I hereby authorize the release of my medical records, as specified in the cover page, to North Bethesda Primary Care.
North Bethesda Primary Care

Fax: 301-941-4404, Phone: 301-941-4414

11300 Rockville Pike, Suite #1015

North Bethesda, MD 20852
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorized Representative (if not the patient)

First NameLast Name
Relationship of Authorized Representative
Phone Number
Format: (000) 000-0000.
Should be Empty: