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.
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.
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.
I authorize the release of my STD results, HIV testing, whether negative or positive to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific writen permission before disclosure of these test results anymore.*

YesNoN/A
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.*

YesNoN/A
Patient's Signature*

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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.
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Authorization to Release Medical Information FROM Dr. Grover