Medical Record Release Form:

Patient Name: ______________________________DOB:_______________

Person Requesting records & relationship:____________________________

Home phone:____________________Daytime Phone:__________________

By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the person (s) or entity listed.

Limitations on the information you may release subject to this release form are as follows:

Release my protected health information to the following person(s) or entity:

Name:_______________________________________________________

Street:________________________________________________________

City:__________________________State:______________Zip:__________

I do_______do NOT__________ give permission for these records to be faxed/ released to the above entity:

The reasons or purposes for this release of information are as follows:

Patient Signature________________________________________________

( or parent, guardian or legal rep) Date:_________________