Authorization to Release Medical Informaiton FROM Dr. Grover

Authorization to Release Medical Information FROM Dr. Grover
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
You are requesting and authorizing Dr. Fred Grover Jr. M.D. to release your medical records to:
Name of Provider:*

First NameLast Name
Address of Provider:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Provider:*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number of Provider:
The Reason For This Request:*
This Request and Authorization Applies To:*
ex: Healthcare information relating to the following treatment, condition, or dates. All Healthcare information.
YesNoN/A
YesNoN/A
Patient's Signature*
Today's Date*

MonthDayYear
Date
The release of a large file of patients' records may incur a $30 fee. Please allow up to 2 weeks for delivery of release.
Should be Empty:

Authorization to Release Medical Information FROM Dr. Grover