ADSCI Medical Records Release Form

Medical Records Release Form

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

First Name Last Name
Date of Birth *

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / 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 Record Biopsy Report(s) Lab Report(s) Consultation Report(s) Medication Allergies Allergy Test/Treatment Surgical Procedures Other
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

City State / Province

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

Please mail Please fax I will pick up
Patient's Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: