New Patient History Form Page 7

ADVERTISEMENT

REQUEST FOR RELEASE OF RECORDS
I, ____________________________________________, request a copy of my complete medical
record from the office of:
________________________________________________________________________________
________________________________________________________________________________
Name and Address of Practitioner
To be sent to Florida Cancer Specialists:
________________________________________________________________________________
Address, City State Zip Code
________________________________________________________________________________
Fax/Telephone Number
I give permission to Fax my medical records to the above listed person, company or medical
______
facility. I understand that my records will be sent via telephone communication.
_________________________________________________________________________________
Provide office fax number
It is my understanding that by signing this authorization for release of my records, I am giving
permission for Florida Cancer Specialists to receive copies of any medical, psychiatric, AIDS, Aids
Related syndromes, HIV Testing, Alcohol and/or drug abuse related information for the above listed
person(s) or organization. I also understand that this authorization may be revoked at any time
except to the extent action has been taken prior to revocation. This consent will expire ninety (90)
days after the date below or sooner at my election.
___________________________________________
__________________________
Print Patient Name
Date
___________________________________________
__________________________
Signature Patient, Parent, or Legal Guardian/Representative
Date
___________________________________________
__________________________
Witness
Date
____________
Patient’s Initials

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

New Patient History Form New Patient History Form Medical
New Patient History Form New Patient History Form Medical
New Patient History Form New Patient History Form Medical
New Patient History Form New Patient History Form Medical
New Patient History Form New Patient History Form Medical
Tower Physio New Patient History Form Tower Physio New Patient History Form Medical
Pediatric New Patient History Form Pediatric New Patient History Form Medical
New Patient History Intake Form New Patient History Intake Form Business
New Patient Medical History Form New Patient Medical History Form Medical
New Patient Health History Form New Patient Health History Form Medical

Related Categories

Parent category: Medical
Download
Go
Page of 7