Medical Record Release Form

Medical Record Release Form
- Patient Name*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
  Date
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Name*
  
  First NameLast Name
- Organization*
- Email
  example@example.com
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number*
  Format: (000) 000-0000.
- Fax
- Patient Care ReportBilling RecordsOther
- Dates of Service From*
  
  MonthDayYear
  Date
- Dates of Service To*
  
  MonthDayYear
  Date
- Purpose of Disclousure*
- Method of Delivery*
- I hereby authorize ProMed Ambulance Company and its affiliates to release or disclose to the person(s) or organization listed above, all medical records requested, which I understand may include specially protected information such as those relating to psychological or psychiatric impairments, drug abuse, alcoholism, sickle cell anemia or HIV infection. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification but that it will not affect any information released prior to notification cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the recipient listed above and will no longer be protected by federal regulations. I understand I can refuse to sign this authorization and my healthcare provider may not condition treatment on my signing this authorization.
- Date
  
  MonthDayYear
  Date
- Relationship to Patient
- Signature
  
  Powered by Jotform SignClear
- Should be Empty: