Medical Records Release/request Form - Enclave Family Healthcare


Medical Records Release/Request Form
(Check One)
_____Releasing information from us to you or your provider
_____Requesting information from another provider to us
Date: _______________
Name: ______________________
Date of Birth: ________________
Address: ______________________________________
Phone: ________________
Social Security #: ____________________
I authorize the Enclave Family Healthcare, PLC to release/request (circle one) the following:
Information Requested:
Purpose of Request: _______________________________
Duration of Authorization: _______________________
To/From (circle one) Name: ________________________________
Address: ________________________________________________
Phone and Fax: ___________________________________________
(It is important that you give as much contact information as you can, especially the provider’s name and
• I understand that this authorization shall be valid through ________________(date), but
that I may revoke it in writing at any time; any such revocation shall have no effect on
disclosures made previously.
• I understand that I have the right to inspect and copy the information to be released.
• I understand that if I refuse to consent to disclosure of information, the agency may be unable
to serve me and/or may be unable to provide the most appropriate care for me.
• I understand that the release of information may not be re-released to any other person or
organization without my written consent.
Signature ___________________________ Date ___________________
Witnessed by ____________________________ Date ___________________


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