AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
I authorize (Name of Facility/Provider)
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
To release health information to:

LOS ANGELES PRIMARY CARE & OBESITY MEDICINE
222 W Eulalia St, Suite 201, Glendale, CA 91204
TEL: 213-238-5887 FAX:213-444-7212
PATIENT PLEASE CHECK EACH ITEM TO BE RELEASED

All medical recordsMedical records from
This date

MonthDayYear
Date
To this date

MonthDayYear
Date
Other
THE PURPOSE OF THIS RELEASE IS: (check all that apply)

At the request of the patientTransferring to another medical doctor/facilityOther
I understand that the release of transfer of the information specified above to any person or entity not specified above is prohibited.

I understand that I may revoke this consent at any time except to the extent that action has already been taken and that it will expire twelve months from the date indicated below.
Signature

Clear
Should be Empty: