Medical Records Release & Communication Consent Form
Patient Information
Full Name
Date of Birth
Address
Phone Number
Email
Recipient Information
Recipient (Person/Organization)
Recipient Address
Recipient Phone
Recipient Fax (if applicable)
Information to Be Released
Please describe the specific records/information to be released
Purpose of Release
Purpose
Communication Consent
I authorize communication via phone.
I authorize communication via email.
I authorize release via fax.
Authorization & Signature
Patient / Legal Representative Signature
Relationship to Patient (if not self)
Date