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
Consent to send:

Other
If you do not consent
This request is valid for 365 days after the signed date.
Signature
Date Signed

MonthDayYear
Should be Empty:

Medical Records Release Authorization