MEDICAL RELEASE OF INFORMATION
PATIENT FULL NAME
*
First Name
Last Name
PATIENT DOB
*
-
Month
-
Day
Year
Date
SEND INFORMATION TO:
RECIPIENT NAME
*
First Name
Last Name
COMPANY NAME
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
INFORMATION TO BE DISCLOSED:
I
blanks
*
authorize the release of the following health information:
Type a question
*
All my health information that the provider has in his possession, including information relating to any medical history, mental or physical condition and any treatment received by me.
Only the records indicated below:
Records authorized to send:
PURPOSE
I authorize the release of my health information for the following specific purpose:
*
At the request of the patient
Other
AUTHORIZATION
I authorize Dr. Alan F. Bain, DO or his staff to release confidential health information about me. You may release a copy of my medical records, or a summary or narrative of my protected health information to the recipient I have addressed above. I understand that this authorization will remain in effect until the provider fulfills this request.
PATIENT SIGNATURE
*
PATIENT FULL NAME
*
First Name
Last Name
Signed
Submit
Submit
Should be Empty: