AUTHORIZATION TO RELEASE MEDICAL INFORMATION
Patient Name
*
First Name
Last Name
Previous name (if any)
Date of Birth
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorize Release of Medical Information From
Physician/Practice Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorize Release of Medical Information To
Physician/Practice Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Fax Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
The information requested is from the medical record maintained while I was a patient under the care of your providers from the dates of
This information is requested for the following reason(s):
These details may include information from other physicians, hospitals & other providers obtained in treatment of this patient, but may not be the complete record of these other providers.
I understand that I may revoke this consent at any time & that upon delivery of the records requested in this release, this consent will automatically expire without my express revocation.
I do not authorize further release to any other party.
A photocopy of this authorization shall be considered as valid as the original.
Signature of Patient or Parent/Guardian
*
Date
*
-
Month
-
Day
Year
Date
Relationship to patient if Parent/Guardian
Submit
Submit
Should be Empty: