Authorization for Release of Medical Records - Endocrinology

Patient Information

Full Name: _________________________________ Date of Birth: //___ Address: ___________________________________________________________ Phone: ________________________ Email: ______________________________

Records To Be Released From

Practice Name: ____________________________________________________ Provider Name: ____________________________________________________ Address: __________________________________________________________ Phone: ________________________ Fax: _______________________________

Records To Be Released To

Practice Name: ____________________________________________________ Provider Name: ____________________________________________________ Address: __________________________________________________________ Phone: ________________________ Fax: _______________________________

Information to be Released

(Check all that apply)

□ Complete Medical Record □ Laboratory Results □ Imaging Reports □ Endocrine Function Tests □ Diabetes Management Records □ Thyroid Function Tests □ Treatment Plans □ Medication Lists □ 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 by submitting a written request
• Information released may include sensitive data regarding endocrine conditions
• A copy of this authorization is as valid as the original

Signature: _________________________________ Date: //___

If signed by representative: Name: _________________________ Relationship: _____________________

For Office Use Only

Received Date: //___ Processed By: __________________________ Release Date: //___ Method: □ Fax □ Mail □ Electronic □ Other