Patient Release Form

Patient Release Form
Patient's Name
Patient's Name

First NameLast Name
DOB

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
REQUESTS RECORDS FROM (WHO HAS YOUR RECORDS NOW):
I hereby authorize:
Medical Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
FAX
TO RELEASE INFORMATION TO (WHO YOU WANT TO RECEIVE YOUR RECORDS):
Name (Person or entity)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
FAX
INFORMATION TO BE RELEASED:
My medical records for the dates:

MonthDayYear
Date
to:

MonthDayYear
Date
Select all that apply:
I understand that the information to be disclosed may include information regarding the following conditions:
Authorization:
This consent is in effect until:
(Ex: 1 year from request date)
This consent is in effect until:

MonthDayYear
Date
Signature of Client or Personal Representative
If I am unable to personally pick up my records from Peak Gastroenterology Associates PC, I authorize:
Name

First NameLast Name
Relationship
Sender
Should be Empty:

Patient's Name