AUTHORIZATION FOR RELEASE AND/OR DISCLOSURE OF MEDICAL INFORMATION

AUTHORIZATION FOR RELEASE AND/OR DISCLOSURE OF MEDICAL INFORMATION
Select which type of information is to be released and/or disclosed:

All Medical RecordsRadiology RecordsLaboratory/Pathology ResultsProgress NotesOther
Name of Patient
Date of Birth

MonthDayYear
Address of Patient

Address

Street Address Line 2

CityState

Zip Code
Telephone Number of Patient
Email Address of Patient
Please REQUEST Medical Records FROM:
Name of Patient's Physician
I hereby authorize the release of the medical information as indicated below to the health care provider, entity, or person I have indicated. Note: the medical record can be sent to yourself or a third party.
Please SEND Medical Records TO:
Name of Recipient
Phone Number
Fax Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This authorization is only valid until the date

MonthDayYear
Date
SIGNATURE OF PATIENT OR PATIENT'S REPRESENTATIVE

Clear
DATE

MonthDayYear
Date
Should be Empty: