Authorization for Release of Medical Records

Patient Information

• Full Name: _________________________ Date of Birth: //___
• Address: ________________________________________________
• Phone: _________________ Email: _________________________

Records to be Released From

• Facility Name: ____________________________________________
• Address: ________________________________________________
• Phone: _________________ Fax: ___________________________

Records to be Released To

• Recipient Name/Facility: ___________________________________
• Address: ________________________________________________
• Phone: _________________ Fax: ___________________________

Information to be Released

• Complete Medical Record
• Lab Results
• Imaging Reports
• Treatment Records
• Immunization Records
• Other (specify): _______________________________________

Date Range

• From: //___ To: //___

Purpose of Release

• Continuing Medical Care
• Insurance
• Legal
• Personal Use
• Other (specify): _______________________________________

Authorization

I understand that:

1. This authorization is valid for 90 days from the date of signature
2. I may revoke this authorization at any time in writing
3. Once information is released, the facility cannot prevent its redisclosure
4. Treatment is not conditioned upon signing this authorization

Signature: _________________________ Date: //___

If signed by person other than patient, state relationship and authority to do so:

For Office Use Only

Date Received: //___ Date Processed: //___ Processed By: _____________________ ID Verified: [ ] Yes [ ] No