Authorization of release of medical records

Authorization For The Release Of Medical Records
By signing this form, I request and authorize Dr. William E. Fox, MD to release or disclose the protected health information below to:
Name (Doctor, family member, spouse, healthcare facility-do not list self):
Address of person listed above:
Cell Phone:
Home Phone:
Fax Number:
Email Address:
example@example.com
The protected health information is being released or disclosed for the purpose of:
coordination of care transfer of care insurance legal communication with family other, please specify: _______________________________________________________________
Patient Legal Name:
Patient DOB:
Patient Signature:

Clear
Date:

Month Day Year
Date
Should be Empty:

Authorization For The Release Of Medical Records