Medical Record Release Permissions Request Form
Patient Information
Full Name
Date of Birth
Address
Phone Number
Email
Recipient Information
Recipient Name or Organization
Recipient Address
Recipient Phone Number
Recipient Fax Number
Information to be Released
Type of Information
All Medical Records
Lab Results
Imaging Reports
Visit Notes
Other
If Other, Specify
From Date
To Date
Purpose of Release
Authorization
I authorize the release of my medical records as described above.
Signature
Date