Medical Records Release

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 physician/person/facility/entity listed below. The information you may release subject to this signed release form is as follows (check all that apply):
- Complete records
- Treatment plans
- Progress notes
- Financial/Insurance information
Patient Name*
First Last
Date of Birth*
MM slash DD slash YYYY
My protected health information will be released to the following
Person #1*
First Last
Relationship*
Phone
Need To Send To Somebody Else?
- No
- Yes
Person #2*
First Last
Relationship*
Phone*
Signature*