Medical Record Request

MEDICAL RECORDS REQUEST
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
I hereby request the following information:

Other
Which office are you primarily seen at?
I hereby authorize Academy Orthopedics, LLC to release medical records as indicated above and understand that records may include information regarding HIV, psychiatric and mental illness, drug/alcohol abuse records, venereal disease and any other statutory protected diseases.
Patient or Legal Guardian Signature
Date

MonthDayYear
Date
- OPTIONAL RELEASE OF INFORMATION:
- PLEASE MAIL RECORDS TO (Name of Practice/Company/Attorney):
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Fax Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Should be Empty:

MEDICAL RECORDS REQUEST