Release of Medical Records
Patient:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Patient's Phone Number:
*
Please enter a valid phone number.
Patient's Email Address:
example@example.com
Patient's Home Address:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
I Authorize WellCare Medical Clinic to Release all my Medical Records Including: Psychiatric Evaluation, Substance Abuse management/treatment, Medical diagnosis (primary care) treatment records and medications prescribed.
*
YES
NO
To (Name of Facility or Individual to be released to?)
*
Phone Number of Facility or Individual to release information to:
*
Please enter a valid phone number.
Fax:
Please enter a valid phone number.
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I understand that by signing below, I am authorizing the release of all or part of my Psychiatric Mental Health, Internal medicine (primary care) or Substance Abuse management and treatment record for the purpose of my treatment and/or pertinent healthcare information as determined by my provider. This release may include records containing information regarding the medical diagnosis and/or treatment of mental illness, and/or drug, and/or alcohol addiction, or abuse to any person, persons, and/or agency listed on this form.
*
YES
NO
Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
If signed above for patient under the age of 18 LIST NAME & RELATIONSHIP TO PATIENT:
Submit
Should be Empty: