Please Consent for Release of Health Information.
Please enter your personal information below.
Full Name
*
Please make sure to put first and last name.
DOB
*
Address
City
State
Zip Code
Phone (Daytime)
E mail
example@example.com
Records are being requested from:
The name of the facility that currently has your records.
Facility Name
*
Address
City
State
Zip Code
Fax
INFORMATION REQUESTED FOR RELEASE
1 year abstract of records (includes Office notes, Operative report, labs, testing)
2-year abstract of records (includes Office notes, Operative report, labs, testing)
Dates of Service Requested From
/
Month
/
Day
Year
Date
Dates of Service Requested To
/
Month
/
Day
Year
Date
Office Visit Notes
Procedure/ Operative Report
Labs
X-Ray Reports
Physical Therapy
Other
Send my records to:
Where would you like your records sent? Please fill out completely to ensure delivery
Name/ Facility
*
Attention
RECORD DELIVERY METHOD
*
E-mail (sent via direct link to a specified email )
Mail
Fax
E mail
*
example@example.com
Fax Number
*
Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Signature
*
Date
/
Month
/
Day
Year
Date
Submit
Should be Empty: