Patient Medical Records Release

Date of Birth

Phone Number

Fax Number

I am the patient, or the legally authorized representative of the patient listed above. I authorize the custodian of records to release my protected health information (or the patient information listed above) to:

Myself

Authorized Person/Company/Organization

Person/Company/Organization Name

(Note: If these records contain any information from previous providers or information about HIV/AIDS or communicable disease including sexually transmitted disease, cancer diagnosis, drug/alcohol abuse, or genetic information, you are hereby authorizing disclosure of this information.)

I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws. By signing below, I represent and warrant that I have authority to sign this document and authorize the user or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.

Signature of patient or authorized representative

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Relationship to Patient

Photo identification issued by a government agency certifying my identity

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Email (please enter if you want a copy of this submission)