palmettospinefl.com - Authorization For Release of Medical Records

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND CHART TRANSFER
I, Name* hereby voluntarily authorize the release of my medical records and the transfer of my patient chart:
Please choose one below
Patient Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last 3 Digits of SSN
Should be Empty:

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND CHART TRANSFER