gsoobgyn.com - Records of Release Personal

Authorization for PERSONAL RELEASE of Medical Records

(Fee due at time of request: $15.00)
Patient Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
I am requesting a copy of my health records and understand a $15.00 fee is due for processing.
I would like these records via:

PaperFlash Drive (in-office pick up)Encrypted Email
For Paper (choose one:)

in-office pick upUSPS mailed to address on file
Encrypted Email
example@example.com
To Release (check all that apply):

Pap SmearLab Reports (specify, if needed)MammogramPathologyBone DensityBone DensityOffice NotesHospital Records
Specific Date(s):
You will be notified regarding this request no later than 30 days from the date it is received. There are limited circumstances where your request may be denied. Certain denial decisions may be reviewed at your request
Signature of Patient

Clear
Date

MonthDayYear
Date
Should be Empty:

Authorization for PERSONAL RELEASE of Medical Records