ADSCI Medical Records Release Form

MEDICAL RECORDS RELEASE FORM

Release and/or disclose records and information regarding:
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
I understand that Based on California Evidence Code Sections 1560-1567, fees may be charged for medical record copies. ADSCI charges $15.00 - $25.00 administrative cost fee for Medical Records Photocopied. Postage is an additional cost.
Complete Medical RecordsBiopsy Report(s)Lab Report(s)Consultation Report(s)Medication AllergiesAllergy Test/TreatmentSurgical ProceduresOther
I hereby authorize the release and disclosure of the medical information as indicated above to the health care provider, entity, or person I have indicated below.

PLEASE RELEASE MEDICAL RECORDS TO:
Name of Health Care Provider or Entity*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number*
Please enter a valid phone number.Format: (000) 000-0000.
Please MailPlease FaxI will pick up
Patient's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

MEDICAL RECORDS RELEASE FORM