Cardiology Records Release Form
Patient Full Name
Date of Birth
Phone Number
Patient Address
Release Records To (Doctor/Hospital/Individual Name)
Recipient Address
Recipient Phone Number
Information to be Released
All Cardiology Records
Specific Records (describe below):
Purpose of Release
Continuing Care
Insurance
Personal Use
Other (specify):
Dates of Service Requested
Additional Comments/Instructions
Signature of Patient or Legal Representative
Date