Record Release Forms for Comprehensive Endocrinology PC

Comprehensive Endocrinology, PC

240 W Passaic Street, Suite 14, Maywood NJ 07607

Telephone: (201) 903-0070 Fax: (201) 322-0287

Dr. Ari Geliebter - Dr. Rebecca Geliebter
MEDICAL RECORDS RELEASE
I hereby request protected health information to be released from the medical record of:
Patient Name:*
Patient's Date of Birth:*

MonthDayYear
Date
Release Records From:*
Send Records to:
Comprehensive Endocrinology, PC
Dr. Ari Geliebter - Dr. Rebecca Geliebter
240 W Passaic Street, Suite 14
Maywood, NJ 07607
Phone 201-903-0070
Fax 201-322-0287
This request and authorization applies to: (check appropriate selection)*

All healthcare information.Only healthcare information relating to the following treatment, condition or date(s):
Treatment, condition or date(s):
I hereby authorize and request the prompt release of medical records without exception, including but not limited to clinical notes, lab tests, pathology reports, radiology reports, messages, prescriptions, consultations and secondary records.
Patient/Guardian Name (Please print clearly):*
Signature of Patient/Guardian:*

Clear
Date:

MonthDayYear
Date
Expiration Date of this Release Form

MonthDayYear
Date
Should be Empty:

MEDICAL RECORDS RELEASE