Release of Medical Recorts

Consent for Release of Medical Records
Today's Date
Your Name

First NameLast Name
Please indicate your doctor’s contact info so we can obtain your medical records. If you are a former patient of Dr. Mintz, you may leave this blank, as we have the information on file.
Doctors' Name and Address

Doctor/Practice Name

Address

CityState

Zip Code
Doctor's Fax Number

Area CodePhone Number
Doctor's Phone Number

Area CodePhone Number
Your Name

First NameLast Name
Your Address

Your Name

Street Address

CityState

Zip Code
Your Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I am presently a patient of Dr. Matthew Mintz in Bethesda, Maryland and do hereby authorize the release of my medical records
From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please Sign in the box using your mouse or keyboard touchpad
Please address correspondence to:

                                      Dr. Matthew Mintz

  6000 Executive Blvd

                                      Suite 315

Rockville, MD 20852

                                      Phone and Fax 1-855-646-8963

* This authorization is valid for 90 days from the date of signature.
Should be Empty:

Consent for Release of Medical Records