AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Patient Name:
*
First Name
Middle Initial
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth:
*
-
Month
-
Day
Year
Date
Patient Phone:
*
Format: (000) 000-0000.
Records Authorized for Release:
Please check appropriate box or boxes:
Records Authorized for Release:
*
COMPLETE RECORD
PROCEDURE REPORT
PATHOLOGY REPORT (Bloodwork, Histology, etc.)
DIAGNOSTIC TEST/ RESULTS (X-RAYs, MRIs, CT scans, and other Radiology Results)
OFFICE VISIT NOTES
For the dates of service starting:
-
Month
-
Day
Year
Date
through
-
Month
-
Day
Year
Date
Check this box for all service dates:
Check this box if you want to send records to another office or receive a copy for yourself: I authorize The Gastro Center of Maryland to disclose my health information to:
(Name of Person or Practice)
Fax #:
Check this box if you want to request records from another office: I authorize:
(Name of Person or Practice)
Fax #:
(Patient Signature)
*
(Date)
*
-
Month
-
Day
Year
Date
Submit
Gastro Center of Maryland
Phone 410-290-6677 Fax 410-290-6676
Should be Empty: