PEMC | RELEASE Form

MEDICAL RECORDS RELEASE AUTHORIZATION FORM

Version 06.2023
Patient Information
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Patient's Date of Brith
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Release Details
Please Indicate the purpose of this authorization: (mark all that applies)*

Further Medical CareChanging PhysiciansPersonalLegal Investigation or ActionDisclosure to a third-partyOther
I authorize the RELEASE of the following Protected Health Information: (mark all that applies)*

Entire RecordLast Visit RecordLaboratory Orders/ResultsX-Ray/Ultrasound Orders and ReportsSurgical ReportsHospital Records and ReportsPrescriptions, Treatments or TestsOther
Release my records TO:
Type the name of the institution or provider
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Patient/Parent/Legal Representative Name*

First NameMiddle NameLast Name
Today's Date*

MonthDayYear
Today's Date recorded
SIGNATURE*

Clear
Should be Empty:

MEDICAL RECORDS RELEASE AUTHORIZATION FORM