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.Format: 0000 000 000.
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 give permission to the above medical practice and its authorised staff or practitioners to release relevant medical information to specific email address. I have been made aware by the staff of potential privacy concerns associated with using email and electronic communications. This may include, but is not limited to:
- Confirmation of consultations or treatment
- Relevant clinical notes or reports
- Referral letters or investigation reports
- Billing or service details related to my care
- Requested medical record or information
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