Medical Record Release Form

Medical Record Release Form
Patient Name
Date of Birth

MonthDayYear
Date
I request and authorize the below listed entity to release medical information to Primary Care House Calls.
Name
Telephone
Address
Address (Line 2)
Fax
Medical Information Requested:
1. All Records
2. Specific Records from
to
3. Immunization & Physical Examinations

4. Radiology Films (X-Ray, Mammography, Ultrasound, CT, MRI, etc

5. Discharge Summary

6. History and Physical

7. Lab Results

8. Consultation
Signature of Patient or Legal Guardian*

Clear
Date

MonthDayYear
Date
I understand that these records are protected under and State law and cannot be disclosed without written consent unless otherwise provided by law. I further understand that the specific type information to be disclosed may, if applicable include: diagnosis, prognosis, and treatment for physical and/or mental illness, including treatment of alcohol for substance abused, auto immune deficiency syndrome (AIDS), AIDS related complex (ARC) or human immunodeficiency virus (HIV) infection for any admission. I understand that I have the right to revoke this consent at any time in writing unless the facility, which is to make the disclosure of information, has already done so in reliance on the consent.
Should be Empty: