Medical Record Release Form

Medical Record Request Form
Full Name

First NameLast Name
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you need to include any dependents on this request?
Please include their name and date of birth
I'd like Reed Optical to
Share/Receive the following records:
Please share my records with:
Name of Office/Provider
Please request copies of my records from:
Name of Office/Provider
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
We are happy to send you your records via fax or email.

Please note that email is unencrypted and is therefore not HIPAA compliant. By requesting records via email, you understand that your information could potentially be compromised if hacked.

By requesting your records via email, you understand and accept these risks.
Email
example@example.com
Fax Number

Area CodePhone Number
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Medical Record Request Form