Authorization to Release Medical Records Form

Authorization to Release Medical Records

Phone: 303-788-8888 or 303-790-7334

Email: medical_records@gutfeelings.com
Physician or Facility to Release Records (From):
Patient Name:*

First NameLast Name
DOB:*

MonthDayYear
Last 4 of SSN:
Information Requested:

Procedure ReportsRadiologyPathology ReportsEntire ChartLab/Blood workOther
Release Records (To):*
Address:
Phone:
Email:
Fax:
By signing this form, I authorize the healthcare provider to release the information listed above, which may include the following:
Drug Abuse, Substance Abuse, Psychological/Psychiatric issues and/or AIDS/HIV.
Patient Signature:*

Clear
Date:*

MonthDayYear
Person Authorized to Sign for Patient:

Clear
Date:

MonthDayYear
Should be Empty: