Authorization for Release of Medical Records
Full Legal Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Minor?
Yes
No
Parent/Guardian Full Name
First Name
Last Name
Parent/Guardian Date of Birth
-
Month
-
Day
Year
Date
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
*
example@example.com
What is being requested?
*
XRAYS
Financial Records
Chart Notes/SOAP
Other
Reason for request
*
Referral for evaluation
Moving
Other
What are you authorizing?
*
For Whole Family Chiropractors to release my records TO another practitioner or imaging center.
For Whole Family Chiropractors to receive records FROM another practitioner or imaging center (to send my records to Whole Family Chiropractors).
Name of Clinic to release records TO:
Name of clinic, practitioner or imaging center
Phone Number to release records to:
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid FAX number.
Format: (000) 000-0000.
Release of records TO practice Email
example@example.com
Address to release records TO:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Clinic to receive records FROM:
Name of clinic, practitioner or imaging center
Phone Number to receive records FROM:
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid FAX number.
Format: (000) 000-0000.
Receive records FROM practice Email
example@example.com
Address to release records FROM:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
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