ADSCI Medical Records Release Form

MEDICAL RECORDS RELEASE FORM

Release and/or disclose records and information regarding:
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I request a copy or summary of the following medical records
I request a copy or summary of the following medical records:

Other
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.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Delivery Instructions
Patient's Signature
Date

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