Medical Records Release Form

By signing this form, I authorize you to release confidential health information about me by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the physician/person/facility/entity listed below

Print Patient Name

DOB

The information you may release subject to this signed release form is as follows:

Medical Records

Billing Records

This medical release form

Terminates on

Does not Terminate

Date

Release My protected information to the following physician/person/facility/entity and/or those directly associated in my medical care:

Name

First Last

DOB

(if applicable)

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone Number:

Signed:

(Patient or Legal Guardian)

Date