Medical Records Release Form
Download a blank fillable Medical Records Release Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medical Records Release Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Medical Records Release Form
Patients 18 and older
This request is directed to the following physician:
□ Victoria Arthur, MD
□ Katharine Garnett, MD
□ Nuria Gine-Nokes, MD, MPH
□ Jesse Lock, MD, PhD
□ Johanna Mailloux, MD
□ Bronson Terry, MD
□ Wendy Wornham, MD
Patient Information:
Last name: _________________________ First name: _____________________ Middle initial: _______
Address: _____________________________________________________________________________
Telephone: ___________________________________ Date of Birth: ___________________________
PLEASE READ CAREFULLY:
THE PATIENT, NOT PARENT, MUST COMPLETE AND SIGN THIS FORM.
WE CAN ONLY RELEASE THE MEDICAL RECORD TO THE PATIENT UNLESS PERMISSION IS GIVEN
BELOW TO RELEASE TO ANOTHER PERSON.
Please complete both sides of this form.
Please allow 2-3 weeks for completion. There is a $15 fee to obtain a copy of your medical
record.
____________________________________________________________________________________
Reason for record request:
□ Changing physicians (Reason:____________________________ Effective date: ______________)
□ Consultation/second opinion
□ Continuing care
□ Legal
□School □Insurance
□ Workers Compensation
□ Other: _______________________________________
Medi cal Record Release Form 18 up
6/2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal