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Authorization For Release Of Medical Records

Fill in the name on the person you want records for on the "(name of person signing)" line and fill your name and address in the "release to" section. Have the person you want records for mail or FAX the completed form into the doctor(s) you want records from. This form may also be modified to include specific records if necessary.

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS



Date _________________________
To ____________________________________
_______________________________________



I, _________________________
(name of person signing)

Address: __________________________
Address: __________________________
City: ________________________, State ________
SS#: ________________________, DOB __________________

hereby authorize you to release to:

(Your name)
(Your Address)
(Your Address)
Phone (XXX) XXX-XXXX
FAX (XXX) XXX-XXXX

any and all information including the diagnosis and records of any treatment or examination rendered to me during the period from [start date] to [stop date].

Please mail or fax any material to the person listed above. If faxing, please include a cover sheet with a statement of confidentiality.

A copy of the signed original record release may serve as the original release.


_______________________
SIGNATURE

_______________________
WITNESS



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