acehealthclinic.com - Medical Release Form

AUTHORIZATION TO RELEASE MEDICAL RECORDS
I, Patient Name DOB Date
I hereby authorize the physician, healthcare provider , hospital, or medical facility listed below to release my medical records to Ace Health and Wellness Center PLLC for the purpose of establishing and/or continuing my medical care.
Please send my records to:

Ace Health and Wellness Center PLLC
Attn:
Address: 14815 N Del Webb Blvd, City: Sun City, State: AZ, Zip: 85351

Phone: (623)248-1717, Fax: (623)248-1688

Please release records from the following physician/ facility
Physician/Facility 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
Please enter a valid phone number.Format: (000) 000-0000.
Please include the following
I request and authorize the above-named doctor or health care provider to release the information specified above to the organization, agency or individual named on this request. I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

AUTHORIZATION TO RELEASE MEDICAL RECORDS