Medical Release Form

Prime Direct Care

Medical Release Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
SSN
Phone
Email
example@example.com
Information Requested From
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Fax
Email
example@example.com
SEND INFORMATION TO
Name
Send by

MailFaxSecure Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
I, Name, hereby grant permission for you to release confidential health information about me, by releasing a copy of my medical record, or a summary or narrative of my protected health information, to the physician/person/facility/entity.
Printed Name
Date

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Information Requested From