Medical Records Release Form printable pdf download

Medical Records Release Form

MEDICAL RECORDS RELEASE FORM

Date:__________________________________

Doctor Name:_____________________________

Fax Number: ________________________

I hearby authorize you to release my records to: Dr. Smith/Dr. Deemer at

Westbrook Vision Center PLC

8877 W. Union Hills Drive Ste 460

Peoria, AZ 85382

PH 623.256.0400

FAX 623.376.6800

Any information, including diagnosis and records, of any treatment or examination rendered to

me during the period from _______________________ to ________________________.

Special instructions:

______________________________________________________________________________

PATIENT:

Printed___________________________________________DOB_________________________

Signature______________________________________________________________________

Medical Records Release Form