Medical Records Release/Request Form

Medical Records Release/Request Form
DUANE M. GELS, MD

129 Lubrano Drive, Suite 200 Annapolis, MD 21401

227 N Liberty Street Centreville, MD 21617

Phone 410.573.1600 Fax 410.573.5841 www.annapollsallergy.com
Patient Name*
First, Middle, Last
Date of Birth*

MonthDayYear
Date
I hereby authorize Doctor/Facility
Please type in Doctor/Facility here
Doctor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor Phone Number

Area CodePhone Number
to release All medical records pertaining to:
The information you may release subject to this signed release form is as follows:

Complete RecordsCare PlanPathology ReportHospital ReportHistory & PhysicalLab ReportsTreatment RecordsMedication RecordProgress NotesRadiology ReportOperative NotesOther
To: Annapolis Allergy and Asthma
227 N. Liberty Street
Centerville, MD 21617

Annapolis Allergy and Asthma
129 Lubrano Drive Suite 200
Annapolis, MD 21401
Signature of Patient or Parent if patient is a minor. "Please use your finger to sign this E-Signature Field"

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