Medical Release

Name*

First NameLast Name

Date of Birth*

Date

This letter will authorize you to provide a copy, summary, or narrative of my medical records (as indicated by the
check mark(s) below) or to otherwise release confidential information to the above address or to myself. At this
time I am requesting the following:

*

Medical Information from the most recent visit/admission to include physician notes/summaries and diagnosticresults.Medical Information including physician notes/summaries and diagnostic results from the past yearOther: Specify information to release below

*

I give permission to share my information with:*

Phone Number of receiving provider*

Fax Number of receiving provider*

Reason to disclose health information

Delivery Method

I understand that you will provide this information within 15 business days from the receipt of request, and you may charge a fee for preparing and furnishing this information.
I understand the following: See CFR. § 164. 508(c)(2)(i-iii)

A. I have a right to revoke this authorization in writing at any time, except to the extent information has
been released in reliance upon this authorization.

B. The information released in response to this authorization may be re-disclosed to other parties.

C. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein.
This authorization shall be in force and effect until 1 year from date of execution at which time this authorization
expires.

Signature

Clear