10-4 Medical Request for Release of Medical Records

REQUEST FOR RELEASE OF MEDICAL RECORDS
This form is intended for use by patients requesting a copy of their medical records for their personal use or for delivery to another physician or medical practitioner participating in their care.
REQUEST STATEMENT:
I request JGK, LLC DBA 10-4 Medical to release my medical records directly to me.I authorize JGK, LLC DBA 10-4 Medical to release my medical records to the medical practitioner/clinic/person/entity named below.
PATIENT SIGNATURE

Clear
DATE

MonthDayYear
Date
PATIENT INFORMATION
Name

FIRST NAMELAST NAME
DATE OF BIRTH

MonthDayYear
Date
LAST 4# OF SSN
PHONE
EMAIL
example@example.com
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP CODE
REMIT ADDRESS
Send By

MailSecure Email
PHYSICIAN/PERSON/FACILITY/ENTITY NAME
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP CODE
PHONE
SECURE EMAIL
example@example.com
AFFIRMATION OF RELEASE
I hereby grant permission for JGK, LLC DBA 10-4 Medical to release my confidential health information, by providing a copy of my medical record, summary or narrative of my protected health information, to the physician(s)/person(s)/facility(s)/entity(ies) named above.
PRINTED NAME
DATE

MonthDayYear
Date
SIGNATURE

Clear
DATE

MonthDayYear
Date
Should be Empty:

PATIENT INFORMATION