MEDICAL RECORDS RELEASE FORM
Patient's Name
Patient DOB
Social security number
I authorize to release all my medical records from the below provided date , including but not limited to, initial psychiatric evaluation, history and physical, progress notes ,procedure notes, medication history and lab reports
To Greater Heights Holistic Psychiatry from the following provider(s):
From Greater Heights Holistic Psychiatry to the following provider(s):
From Date
Provider's Name / Institution Name
Patient Address
Patient Phone Number
Fax Number
I understand that this form will be in effect for 1 year after termination of care from Greater Heights Holistic Psychiatry clinic. I understand that I can revoke this consent in writing at any time.
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Clear
