Medical Records Release Form

Patient Name *

Date of birth

Email

Phone

Street Address

Name Of Patient Provider

Patient Provider Address

Patient Provider City

Patient Provider State

Patient Provider Phone number

Patient Provider Fax number

Patient Provider Zip Code

Please select all that apply to your request: check boxes

Clinical Notes

Lab Results

Radiology Report

Pathology Reports

History & Physical

List of Medications

Discharge Summary

Please Indicate by checking off beside the options below which information you would like to NOT disclose:

Drugs or Alcohol

Genetic Testing

HIV/AIDS/ other infectious disease

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