Authorization for Release of Medical Records

Patient Information

Name: _________________________________ Date of Birth: _______________ Address: _______________________________ Phone: ____________________

Records to be Released From

Practice Name: __________________________ Address: _______________________________ Phone: _________________ Fax: _________________

Records to be Released To

Name/Facility: ___________________________ Address: _______________________________ Phone: _________________ Fax: _________________

Information to be Released (Check all that apply)

□ Complete Medical Record □ Office Visit Notes □ Laboratory Results □ Endoscopy Reports □ Colonoscopy Reports □ Pathology Reports □ Imaging Reports □ Other: _________________

Date Range

From: _____________ To: _____________

Purpose of Release

□ Continuing Care □ Personal Records □ Insurance □ Legal □ Other: _________________

Authorization

I understand that:

• This authorization is valid for 90 days from the date of signature
• I may revoke this authorization at any time in writing
• Information used or disclosed may be subject to redisclosure
• Treatment is not conditioned upon signing this authorization

Signature: _______________________________ Date: _______________

If signed by representative: Name: _________________________________ Relationship: _______________

For Office Use Only

Request received: _____________ Processed by: _____________ Records sent: _____________ Method: □ Fax □ Mail □ Other