Authorization For Release Of Medical Records
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1AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Patient Name:
Birth date:
ID #:
Telephone:
Address:
Release From: (Name of Facility of Clinician Releasing Information):
I authorize release of my medical records from:
Facility/Name of Physician:
_____ Saint Peter’s University
Other
(Specify)
Address: (If different form Saint Peter’s University facility):
Release To: (Name of Facility/Clinician/Person Receiving Information):
Please send my medical records to:
Name:
Telephone #:
Complete Address:
Fax #:
Release Information:
Reason: ___ Moving out of area ___ Requirement for school ___Personal file
Please Release the Following: (check all that apply)
____ Immunizations
____ Laboratory Results Only (specify)
____ Other information (specify)
Consent:
This information is intended by the above named recipient only. I have a right to receive a
copy of this authorization. I may revoke this authorization at any time in writing
Signature of Patient:
Date:
Witnessed by:
Date:
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Parent category: Legal