ADSCI Medical Records Release Form

Medical Records Release Form

Release and/or disclose records and information regarding:
Patient*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
I understand that based on Based on California Evidence Code Sections 1560-1567, fees may be charged for medical record copies. ADSCI charges $15.00-$25.00 administrative cost fee for Medical Records Photocopied. Postage is an additional cost.*

Yes
I request a copy or summary of the following medical records:*

Complete Medical RecordBiopsy Report(s)Lab Report(s)Consultation Report(s)Medication AllergiesAllergy Test/TreatmentSurgical ProceduresOther
I hereby authorize the release and disclosure of the medical information as indicated above to the health care provider, entity, or person I have indicated below.
PLEASE RELEASE RECORDS TO:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Delivery Instructions*

Please mailPlease faxI will pick up
Patient's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: