Patient Records Release Form

Patient Records Release Form
Please fill out this form to authorize the release of your medical records.
Patient Full Name*
First NameLast Name
Date of Birth*
MonthDayYear
Date
Patient Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Recipient Name (Person or Organization)*
Recipient Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Please specify what records you authorize to be released (e.g., all records, specific dates, specific types).*
Authorization Signature*
Clear
Date of Authorization*
MonthDayYear
Date
Should be Empty: