Medical Record Release
Note: Please fill in all blanks.
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Patient Information
First Name:
Last Name:
Phone Number:
Alternate Phone Number:
Email:
Date of Birth:
January
February
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October
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December
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SSN:
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Release Records to:
Medical Facility:
Name of Physician:
Address:
City | State | Zip:
Comments:
By typing my name in the box below, I am authorizing the release of my medical records from Dr. Smith's Office to the Physician at the Facility mentioned above. Your signature here must match the first and last name given in the form (i.e., Firstname Lastname).
