harteyecare.net - Records Release Form (English)

RELEASE OF MEDICAL RECORDS AUTHORIZATION FORM
Patient Information:
Patient Name:
Patient Date of Birth:

MonthDayYear
Date
Address:
Home Phone#:
Please enter a valid phone number.
Work Phone#:
Please enter a valid phone number.
Cell Phone#:
Please enter a valid phone number.
I am requesting my medical records be released from:
Clinic/Doctor:
Address:
Phone#:
Please enter a valid phone number.
Fax#:
I am requesting my medical records be released to:
Physician/Clinic/Other:
Address:
Phone#:
Please enter a valid phone number.
Fax#:
Please check ONE of the following:

I wish to obtain a summary of the requested recordsI wish to inspect the requested records (in the office)I wish to obtain a copy of the requested records (fees may apply with this option)I wish to inspect and obtain a copy of the requested records (fees may apply with this option)I wish to communicate electronically* knowing that standard email and text communication may not be totally secure, I still consent to communications from my doctor or staff through my standard email and texting devices.
*This can include written and verbal communications if necessary
Details if necessary:
I hereby authorize the release of a copy of the patient’s medical records as requested.
Authorizing Person’s Name:
(Patient, Parent, or Guardian)
Relationship to Patient:
If you are legally authorized representative of the patient, please sign, date and indicate your relationship to the patient. You may be asked to provide documents showing that you are the patient or patient's legally authorized representative.
Authorizing Signature:

Clear
(Patient, Parent, or Guardian)
Date:

MonthDayYear
Date
This consent will expire in 1 year from the date of your signature, unless you indicate an earlier date or event.
Should be Empty:

RELEASE OF MEDICAL RECORDS AUTHORIZATION FORM

Patient Information:

I am requesting my medical records be released from:

I am requesting my medical records be released to: