Authorization to Obtain Healthcare Information

Authorization to Obtain Healthcare Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
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*

Clear
Date*

MonthDayYear
Date
Authorized Representative (if not the patient)

First NameLast Name
Relationship of Authorized Representative
Phone Number
Should be Empty: