Medical Release Form

MEDICAL RELEASE FORM

Dear Doctor __________________ :

This letter will authorize you to provide a copy, summary, or narrative of my Medical Records (as indicated by the check mark(s) below) or to otherwise release confidential information. At this time I am requesting the following:

__________ Complete record

__________ Records of care from _____________________ to ________________ only

__________ Records of care concerning the following condition(s)

________________________________________________________________________

__________________________ Other. Specify: ______________________________________________________

__________ Confer with another person (family member, friend) orally about information in my Medical record

HIV/AIDS . I consent to the release of any positive or negative test result for AIDS or HIV infection, antibodies to AIDS, or infection with any other causative agent of AIDS, with the rest of my medical records.

Initial Date _________________

to the following person(s):

_______________________________________________________________

Name

_______________________________________________________________

Street

_______________________________________________________________

City State Zip

The reasons or purposes for this release of information are:

________________________________________________________________________

I understand that you will provide this information within 15 business days from receipt of request, and you may charge a fee for preparing and furnishing this information.

Signed:________________________

Date: _________________________

(Patient or person legally authorized to consent on patient's behalf)

Patient/Client Name ____________________________________

Date of Birth ____/____/____

Social Security Number ______-___-_______

Address _____________________________________

____________________________________________

Telephone Number (____) ____-_______

Please release my medical records from:

Name of Provider __________________________________________

Provider's Address __________________________

_________________________________________

__________________________________________

Provider’s Telephone Number: ___________________

Provider’s Facsimile Number: ___________________

TO:

[ATTORNEY'S NAME AND ADDRESS HERE]

Please release all records, including but not limited to, progress notes, operative notes, laboratory test results, diagnostic tests, and x-rays.

I HEREBY AUTHORIZE THE RELEASE OF MY MEDICAL RECORDS AS PROVIDED ABOVE.

_______________________________________ Date: ______________________________

Patient's/Client’s Signature