Medical Records Release

Medical Records Release
Patient Name
Date of Birth

MonthDayYear
Date
Social Security Number
I authorize physician/medical office to release the requested medical information to Integrated Health Centers of WV:
Name of Health Care Professional or Facility
Physician/Medical Office Address:
Physician/Medical Office Phone:
Please enter a valid phone numberFormat: (000) 000-0000.
Physician/Medical Office Fax:
Please enter a valid fax numberFormat: (000) 000-0000.
Description of Information to be released:

Other
Please list treatment/conditions
Healthcare information for specific dates; from

MonthDayYear
Date
Healthcare information for specific dates; to

MonthDayYear
Date
Purpose for this Request:
I acknowledge and consent that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDs information:
Please type your initials
Please type your initials
Authorization valid for:
Date authorization is valid until

MonthDayYear
Date
I understand that I may cancel this authorization at any time but submitting a written request, except where a disclosure has already been made in reliance on my prior authorization.
Is the patient under 18?
Relationship to patient
Signature
Date

MonthDayYear
Date
Should be Empty: