Medical Release Authorization for Patient Medical Records

Medical Records Release Authorization
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number
Format: (000) 000-0000.
Cell Number*
Please enter a valid phone numberFormat: (000) 000-0000.
Work Number
Format: (000) 000-0000.
I request and authorize the release of my patient medical records TO the office of:
Physician / Practice Name
Phone
Fax
Please release my medical records FROM the office of:
Physician Name*
Phone*
Format: (000) 000-0000.
Fax*
All Medical RecordsOther
I do NOT consent to the release of my personal and mental health information, which may include the following: all personal health information related to sexually transmitted disease(s), acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), as well as information about behavioral or mental health services, and/or treatment for alcohol and/or drug abuse.
This request is valid for 365 days after the signed date.
Signature*

Clear
Date Signed*

MonthDayYear
Should be Empty:

Medical Records Release Authorization