Quote:
Originally Posted by Jo55
Records Release form {example}
Patient’s name _____________________________________________
Date of birth ____/____/____
Social Security Number ______-___-_______
Address
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Telephone number (____) ____-_______
Please release my medical records from:
Name of provider
__________________________________________
Provider’s address
__________________________________________
__________________________________________
__________________________________________
__________________________________________
TO:
[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 Signature:________________________________________
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Oh wow, Thank you so much.