Physical Therapy Medical Records Release Authorization

Patient Information

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

Records to be Released From

• Facility/Provider Name: ____________________________________
• Address: ________________________________________________
• Phone: _________________ Fax: ___________________________

Records to be Released To

• Facility/Provider Name: ____________________________________
• Address: ________________________________________________
• Phone: _________________ Fax: ___________________________

Information to be Released

• Complete Physical Therapy Record
• Treatment Notes
• Progress Reports
• Exercise Programs
• Initial Evaluation
• Discharge Summary
• Billing Records
• Other: _______________________________________________

Date Range

From: //___ To: //___

Purpose of Release

• Continuing Care
• Insurance
• Legal
• Personal Use
• Other: _______________________________________________

Authorization & Understanding

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. Information disclosed may be subject to redisclosure by the recipient
4. I have the right to receive a copy of this authorization

Signature: _________________________ Date: //___

If signed by person other than patient: Name: _________________________ Relationship: _____________

For Office Use Only

Request received: //___ Processed by: ________________ Records sent: //___ Method: □ Fax □ Mail □ Electronic