Online Medical Record Release Authorization

Medical Record Release Authorization

P.O. Box 30643 Savannah, GA 31410
Request Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
- Patient Name
  
  First NameMiddle NameLast Name
- Is the patient known by any other names?
- If yes, what other name(s)?:
- Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Is the patient under 18 years of age or legally incompetent?
- Patient Representative (Power of Attorney or Legal Guardian)
  
  First NameMiddle NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Format: (000) 000-0000.
- Email Address
- Sender's Information
- Corstrata, Inc.
  P.O. Box 30643
  Savannah, GA 31410
  Phone #: (800) 566-1307
  Fax #: (855) 236-5024
  Email: Privacy@Corstrata.com
- By checking this field, I agree to the below terms:
- Recipient's Information
- Recipient's Name or Organization
- Recipient's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Recipient's Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Recipient's Fax Number
  Please enter a valid fax number.Format: (000) 000-0000.
- Recipient's Email
  example@example.com
- Method of Release to Recipient
- Purpose of Release
  
  Other (please specify):
- Date Range From:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Date Range To:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Information to be released:
  
  Other (please specify):
- Authorization is valid until:
  
  Other (please specify date):
- I wish to have Corstrata redact the following information from the records prior to disclosure:
- By checking this field, I agree to the below terms:
- Print Full Name
- Completed/Signed by:
- Signature
- Please attach a copy of your government-issued ID and/or proof of relationship, if patient representative.
  
  Cancelof
- Should be Empty:

Medical Record Release Authorization

Sender's Information

Recipient's Information