Medical Records Request Form

Medical Records Request Form
Family Medicine Associates | 419 W. Wackerly St. | Midland, MI 48640

P: (989) 631-9515 | F: (989) 835-6824
Medical Records Request Form
I, First Name* Last Name* DOB: Date*

Authorize Family Medicine of Midland to obtain the following medical information:
From
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Other
This release also specifically allows the release of the following information (this information will be released unless the appropriate box is checked.)
This information is being released for the following purpose(s) only and is not to be used for any other purpose or released to any other person(s) without my written consent.

Other
Upon receipt there is potential for the PHI to be re-disclosed by recipient, and thus no longer protected by the HIPAA Privacy Rule. At any time this authorization may be revoked upon signed written request.
Patient Name

First NameLast Name
Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Patient/Legal Guardian of Patient
Date

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