Release of Medical InformationPermission to get records Patient name (required) Patient’s DOB (required) Doctor’s or hospital name who has records (required) Permission to get sensitive informationBy putting my initials by each item below, I understand that I give permission for records to be sent that may contain information about: my mental health, (required) transmittable disease I may have like HIV/AIDS, (required) genetic records, and/or (required) drug and alcohol records. (required) I understand that: I do not have to give my permission to share these records. If I want to take away the permission for my doctor to get these records, I need to talk to my doctor or a staff person and sign a paper. This form is only good for 3 months from the date I sign it. Patient’s Signature (required) Date (required) Authorized Representative’s Signature (required) Date (required) Relationship of Authorized Representative (required) Consent for release of medical records for (required) Date: (required) Requesting records from: Name of Practice: (required) Name of Physician: (required) Fax number: (required) Address: (required) Types of records we are requesting Any and all types of records you have for this patient Doctor visit notes Emergency Room notes Urgent care notes History and physical Hospital Progress Notes Operation or procedure notes Clinic notes Pathology reports Doctors orders Nurses notes Discharge Summary Lab reports Radiology Reports Consultations Other Records within the following dates: All records for this patient Records dated between Please send records to: Attention: (required) At fax number: (required) Email address (required) For any questions please call: (required) and ask for: (required) This field should be left blank Send Please wait...
