perfectbalancehealthcare.com - Medical Records Release Form

Judith Crabtree, WHNP
I hereby authorize Name Phone Area Code Phone Number Fax Type Fax
To release medical records and information of the following patient to Type a label
Patient Name:
Address:
Phone Number:
Please enter a valid phone number.
Date of Birth:

MonthDayYear
Date
Records Requested:
All Records:
Labs:
Other:
All information about the care and treatment of the above named patient may be released, including but not limited to information about general medical care, outpatient treatment with a psychotherapist, and substance abuse/ chemical treatment, unless specific restrictions are listed below.
Restrictions:
Disclosure of records/ information may be used only for the purpose of patient care.
Patient Signature

Clear
Date

MonthDayYear
Date
If form is not signed by the patient please indicate relationship of signer:
The authorization expires on:

MonthDayYear
Date
I am aware there may be a charge for this service as governed by the California Health and Safety Code #123110
Should be Empty:

Judith Crabtree, WHNP