sballergy.com - Medical Release Form

AUTHORIZATION FOR RELEASE MEDICAL INFORMATION
This authorization to release medical information is being requested of you to comply with the terms of the Confidentiality of Medical Information Act (California Civil Code, Section 56, et. Seq.). The purpose of this request is to make available medical information to continue care for:
Name of Patient

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
I authorize the release of any discussion relating to all medical information, including Initial History, Physical and Progress notes for the last seven (7) years and the following:

Other
Records Requested From:
Name of Physician/Clinic

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Send Records To:
Name of Physician/Clinic

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
This authorization shall be effective on Date and shall remain in effect indefinitely.
Signature of Patient/Parent or legal guardian
Date

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR RELEASE MEDICAL INFORMATION