RRMC Medical Record Release Consent Form

Medical Record Release Consent Form

CONSENT FOR THE RELEASE OF MEDICAL RECORDS
Introduction
This consent form is used to request medical records to be received by a specific patient to a specific email address.
Patient Details
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Photo ID*

This must be a legal and Government issued proof of identification in the format of JPG, JPEG, or PNG.
Cancelof
Appointment Date*

DayMonthYear
Email for Medical Records*
The email address where we should electronically send your medical records.
Is there anything you'd like us to know?
A message to the team.
I hereby authorize the release of my medical records to the specified email address. I have been made aware by the staff of potential privacy concerns associated with using email and electronic communications.
Signature*

Clear
Please note: Anyone aged 18 or over must sign their consent for the release of medical records.
Should be Empty:

Medical Record Release Consent Form