Medical Record Release Authorization

I, (please enter full name), authorize ICAM Institute of Amarillo, LLC to release any and all medical records to myself via fax, email, or mail. I realize that any fax or email may be sent unencrypted. I also authorize the following person(s) to request this information on my behalf, as well as discuss patient medical records.
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
ICAM may disclose the following information (please check ALL 3 to give us full permission to send any part of your chart)

Entire Medical RecordTest ResultsMost Recent Chart Note
This authorization is in force 12 months from the date listed above.
Signature of patient

Clear
Signature of legal guardian (if applicable)

Clear
------------------------------------------- OR ---------------------------------------------
**ONLY SIGN BELOW IF YOU ARE DENYING THE ABOVE AUTHORIZATION
I, (please enter full name), request that patient medical records only be released upon my request via my physical presence in the office of ICAM Institue of Amarillo, LLC.
This authorization is in force 12 months from the date listed above.
Signature of patient

Clear
Signature of legal guardian (if applicable)

Clear
Should be Empty:

**ONLY SIGN BELOW IF YOU ARE DENYING THE ABOVE AUTHORIZATION