Medical Records Release Authorization printable pdf download

Medical Records Release Authorization

MEDICAL RECORDS RELEASE AUTHORIZATION

I hereby authorize and request you release a complete copy of my medical

records to:

Adam Cohen, MD

Internal Medicine and Geriatrics

2800 Marcus Avenue – Suite 203

Lake Success, NY 11042

Telephone 516-775-9090

Fax 516-775-3080

Name of Patient: _________________________________________________

Address of Patient: _______________________________________________

Signature of Patient or

Patient's designated

representative____________________________________________________

Date__________________________

Print Your Name (if different from

patient's)________________________________________________________

Name, Address, Phone and Fax of Physician from whom you are

requesting records:

________________________________________________________________

Medical Records Release Authorization