Medical Records Request Form

Medical Records Request Form
Patient Last Name, First Name*
Last Name, First Name
Patient DOB*

MonthDayYear
Patient Email*
example@example.com
I, the undersigned, authorize the release of the medical information specified below from the medical records of the above named patient:
Information to be released (may include, but not limited to):*

Medical HistoryAudiology ResultsLaboratory Test ResultsRadiology ReportOther
If other, please specify*
Purpose of Release of Medical Records:*

Further Medical CareChange of Physicians
The above information may be released to:
Name of Person/Entity*
Phone Number of Person/Entity
How the records are to be released*

MailFaxEmailPick Up
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number*
Email Address of Person/Entity*
Office Location*

FriscoMcKinneyPlanoProsperAnna
Right to Inspect or Copy the Health Information to be Disclosed
You have the right to inspect or copy the health information that is to be used or disclosed. You may obtain access to your health information or obtain copies by contacting the Privacy Officer. We recommend you keep a copy of your
medical records for your files.

Right to Refuse to Sign this Authorization
You have the right to refuse to sign this authorization. ENTTEX will not condition your treatment, payment, and enrollment in a healthplan or eligibility for benefits on whether you provide authorization for the requested use or disclosure.

Signature
I have had an opportunity to review and understand the content of this authorization form. By signing this authorization,I am confirming that it accurately reflects my wishes.
Signature of Patient, Parent/ Legal Guardian

Clear
Signee*
Name of person signing form
Relationship To Patient*
ex. spouse, parent
Please verify that you are human*
Should be Empty: