Patient Care Records Authorization
Authorize the release of your patient care records by completing this form.
Patient Full Name
*
First Name
Last Name
Patient Contact Information
*
Recipient Name or Organization
*
Relationship to Patient or Role (if organization)
*
Purpose of Records Release
*
Please Select
Continuing care
Insurance
Legal
Personal use
Other
Records to be Released (select all that apply)
*
Medical history
Treatment records
Lab results
Imaging (X-rays, MRI, etc.)
Billing information
Other
Authorization Period (Start Date)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorization Period (End Date)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Patient or Legal Representative
*
Authorize Release
Authorize Release
Should be Empty: