Authorization for Release of Medical Records - General Surgery

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Release Information From

Practice Name: _________________ Phone: ___________________ Address: _______________________ Fax: _____________________

Release Information To

Recipient Name: ________________ Phone: ___________________ Address: _______________________ Fax: _____________________

Information to be Released

• Complete Medical Record
• Operative Reports
• Laboratory Results
• Imaging Reports
• Consultation Notes
• Progress Notes
• Other: ___________________

Date Range

From: _____________ To: _____________

Purpose of Release

• Continuing Care
• Insurance
• Legal
• Personal Use
• 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 conditional upon signing this authorization

Signature: _____________________ Date: ___________________

Witness: _______________________ Date: ___________________

For Office Use Only

Date Received: _________ Date Processed: _________ Processed By: _________