Download the Release of Medical Information form here.
Please fill out all highlighted sections, including:
- Patient’s Name, Date of Birth, Address and Phone Number
- Facility Authorized to Release Information to:
- Records Released to you – write in “SELF”
- Records Released to another Provider or Facility – please fill in the Providers name, address, phone and FAX number.
- Health Information to be disclosed – include all dates of service, what type of records you want released (labs, x-ray, complete, etc.), why you need the information (treatment, insurance, personal),
- The Yes/No question is an authorization to release any sensitive information. Typically this should be marked yes if you require all of your information to be released.
- Patient’s or Authorized Personal Representative’s Signature – please sign, date and time.
- Leave the Witness Signature line and everything below it blank.You will also need to include a legible copy of your driver’s license or your Official ID so we may verify your signature with your hospital record.