Medical Records Release

Release Records from the following facility (provide as much info as possible)
I hereby authorize the provider / facility listed below to release records on my behalf:
HealthCare Provider / Physician Name

TitleFirst NameLast Name
Hospital / Practice Name
Phone Number
Fax Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please send all records to the following:

Medical Partners of Florida
8043 Spyglass Hill Rd, Suite 102
Melbourne, FL 32940

(321) 757-6899 phone / (321) 757-6859 fax
MA@MedicalPartnersOfFlorida.com email

Release Details
I, the patient, authorize and request the disclosure of all protected health information listed here:.

All medical records with every page included.Other
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Medical Records Release Form