STATUS:
*
NEEDS ATTENTION
ADDED TO PATIENT'S CHART
General Release
AUTHORIZATION for RELEASE of MEDICAL RECORD INFORMATION
HIPAA-Compliant
Name
*
First Name
Last Name
Birth Date
*
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Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Last 4 SSN
*
I Authorize Medical Record Disclosure From
the following healthcare facility or physician
Facility or Physician Name
Address
Facility or Physician Phone Number
-
Area Code
Phone Number
Facility or Physician Fax Number
-
Area Code
Phone Number
Facility/Physician Phone Number
Facility/Physician Fax Number
Address*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I Authorize Medical Record Disclosure To
the receiving healthcare facility or physician
Organization
Phone Number
Fax Number
Address
Street Address
City, State, Zip Code
City, State, Zip Code
Information Requested: I authorize release of the following health information:
*
Last 3 Office Visit Notes/Progress Notes
Discharge Letter (if patient was under pain management or receiving opioid medications)
All Imaging Reports: X-Rays, MRI's, CT's
EMG/Nerve Conduction Test Reports
Medical History, hospitalizations
Mental health records, diagnosis, and/or treatments (if needed)
Other
Purpose: I authorize the release of my health information for the following specific purpose:
*
New or Continued Medical Care
Legal Purposes
Insurance Purposes
Personal Injury
Other
Consent
*
I understand that this release is valid when I sign it and will remain in effect until the Provider fulfills this request, until I am no longer a patient of this practice, or until I revoke this request in writing.
e-Signature
*
Have you had any imaging (MRI/CT/Xrays) in the past few years or any previous treatment at a clinic for your pain? If so, please release records or imaging reports by providing additional information:
*
Yes
No
Specific Release
AUTHORIZATION for RELEASE of MEDICAL RECORD INFORMATION
HIPAA-Compliant
Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
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14
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19
20
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22
23
24
25
26
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28
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30
31
Day
Please select a year
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2025
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2022
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2020
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2018
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1944
1943
1942
1941
1940
1939
1938
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Last 4 SSN
*
I Authorize Medical Record Disclosure From
the following healthcare facility or physician
Facility or Physician Name
*
Facility or Physician Phone Number
*
Format: (000) 000-0000.
Facility or Physician Fax Number
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
I Authorize Medical Record Disclosure To
the receiving healthcare facility or physician
Organization
Phone Number
Fax Number
Address
Street Address
City, State, Zip Code
City, State, Zip Code
Information Requested: I authorize release of the following health information:
*
Last 3 Office Visit Notes/Progress Notes
Discharge Letter (if patient was under pain management or receiving opioid medications)
All Imaging Reports: X-Rays, MRI's, CT's
EMG/Nerve Conduction Test Reports
Medical History, hospitalizations
Mental health records, diagnosis, and/or treatments (if needed)
Other
Purpose: I authorize the release of my health information for the following specific purpose:
*
New or Continued Medical Care; Evaluation and/or Treatment
Legal Purposes
Insurance Purposes
Personal Injury
Other
Consent
*
I understand that this release is valid when I sign it and will remain in effect until the Provider fulfills this request, until I am no longer a patient of this practice, or until I revoke this request in writing.
e-Signature
*
Any other facility or clinic where imaging (MRI/CT/Xrays) was done or any other clinic that provided treatment for your pain? If so, please release records or imaging reports by providing additional information:
*
Yes
No
Specific Release
AUTHORIZATION for RELEASE of MEDICAL RECORD INFORMATION
HIPAA-Compliant
Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Last 4 SSN
*
I Authorize Medical Record Disclosure From
the following healthcare facility or physician
Facility or Physician Name
*
Facility or Physician Phone Number
*
Format: (000) 000-0000.
Facility or Physician Fax Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I Authorize Medical Record Disclosure To
the receiving healthcare facility or physician
Organization
Phone Number
Fax Number
Address
Street Address
City, State, Zip Code
City, State, Zip Code
Information Requested: I authorize release of the following health information:
*
Last 3 Office Visit Notes/Progress Notes
Discharge Letter (if patient was under pain management or receiving opioid medications)
All Imaging Reports: X-Rays, MRI's, CT's
EMG/Nerve Conduction Test Reports
Medical History, hospitalizations
Mental health records, diagnosis, and/or treatments (if needed)
Other
Purpose: I authorize the release of my health information for the following specific purpose:
*
New or Continued Medical Care; Evaluation and/or Treatment
Legal Purposes
Insurance Purposes
Personal Injury
Other
Consent
*
I understand that this release is valid when I sign it and will remain in effect until the Provider fulfills this request, until I am no longer a patient of this practice, or until I revoke this request in writing.
e-Signature
*
Any other facility or clinic where imaging (MRI/CT/Xrays) was done or any other clinic that provided treatment for your pain? If so, please release records or imaging reports by providing additional information:
*
Yes
No
Specific Release
AUTHORIZATION for RELEASE of MEDICAL RECORD INFORMATION
HIPAA-Compliant
Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Last 4 SSN
*
I Authorize Medical Record Disclosure From
the following healthcare facility or physician
Facility or Physician Name
*
Facility or Physician Phone Number
*
Format: (000) 000-0000.
Facility or Physician Fax Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I Authorize Medical Record Disclosure To
the receiving healthcare facility or physician
Organization
Phone Number
Fax Number
Address
Street Address
City, State, Zip Code
City, State, Zip Code
Information Requested: I authorize release of the following health information:
*
Last 3 Office Visit Notes/Progress Notes
Discharge Letter (if patient was under pain management or receiving opioid medications)
All Imaging Reports: X-Rays, MRI's, CT's
EMG/Nerve Conduction Test Reports
Medical History, hospitalizations
Mental health records, diagnosis, and/or treatments (if needed)
Other
Purpose: I authorize the release of my health information for the following specific purpose:
*
New or Continued Medical Care; Evaluation and/or Treatment
Legal Purposes
Insurance Purposes
Personal Injury
Other
Consent
*
I understand that this release is valid when I sign it and will remain in effect until the Provider fulfills this request, until I am no longer a patient of this practice, or until I revoke this request in writing.
e-Signature
*
Date
*
-
Month
-
Day
Year
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Date
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*
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