First Name:
*
Middle:
Last:
*
Date of Birth:
*
/
Month
/
Day
Year
Address:
Home or Mailing Address
City:
State:
Zip:
Telephone: Home:
Work:
Cell:
Email:
example@example.com
I, (Name) approve records to be requested
First and Last Name
From:
Facility where records will be requested from.
Type of Records
All Records
Consultation Notes
Discharge Summary
Office Visits
Hospital Records
Procedure Notes
Emergency Department Records
Surgery/Operative Reports
Pathology/Lab Reports
Radiology Reports (Ultrasounds, X rays, MRI, CT scans)
All Dates
All Dates
Date Range:
Dates from _____ to _____
Specific dates of records to be requested, if "Date Range" was selected.
I do or do not authorize release of information related to AIDS, HIV infection, sexually transmitted diseases, psychiatric care and / or psychological assessment, and treatment for alcohol and/ or drug abuse.
I do
I do not
Patient Name:
First and Last Name
Date:
/
Month
/
Day
Year
Todays date
Signature:
*
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