acehealthclinic.com - Medical Release Form

AUTHORIZATION TO RELEASE MEDICAL RECORDS
I, Patient Name DOB Date

Authorize, 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.
To release my records to
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
Date
Should be Empty:

AUTHORIZATION TO RELEASE MEDICAL RECORDS