ADSCI Medical Records Release Form

Patient Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

I request a copy or summary of the following medical records*

I understand that Based on California Evidence Code Sections 1560-1567, fees may be charged for medical record copies. ADSCI charges $15.00 - $25.00 administrative cost fee for Medical Records Photocopied. Postage is an additional cost.

I request a copy or summary of the following medical records:*

I hereby authorize the release and disclosure of the medical information as indicated above to the health care provider, entity, or person I have indicated below.

PLEASE RELEASE MEDICAL RECORDS TO:

Name of Health Care Provider or Entity*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Fax Number*

Please enter a valid phone number.

Delivery Instructions*

Please MailPlease FaxI will pick up

Patient's Signature*

Date*

Date

MEDICAL RECORDS RELEASE FORM