Medical Records Release Form
Patient Name:
Date of Birth:
Patient Address:
Email (to receive PDF):
Requesting Medical Records From:
Provider’s Fax #:
Attention To:
Comments/Notes:
Release records dating back since:
Information to Release:
Physician Notes
Labs/Xrays
Consultation Notes
Hospitalization/ED
Telehealth Calls
Signature (draw below):
Clear Signature
Submit Form
