Generic Medical Records Release Form

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Our collection of online health templates aims to make life easier for you. Our site is updated every day with new health and healthcare templates. By providing you this health Generic Medical Records Release Form template, we hope you can save precious time, cost and efforts and it will help you to reach the next level of success in your life, studies or work!

Patient’s Name Birth date (Please Print) LAST FIRST MI Are medical records filed under another name Phone Number INFORMATION TO BE RELEASED BY: INFORMATION TO BE RELEASED TO: REQUEST MUST HAVE COMPLETE ADDRESS OR FAX NUMBER REQUEST MUST HAVE COMPLETE ADDRESS OR FAX NUMBER Organization/Person Name Organization/Person Name Street Address Street Address City, State, Zip City, State, Zip Phone Phone Fax Fax TYPE OF MEDICAL INFORMATION REQUESTED:  Complete medical record abstract (includes 3 years of chart notes, most recent labs/pathology diagnostic imaging reports)  Cancer Partnership records  Radiology/ Diagnostic Imaging (CD/Films)  Mammogram Diagnostic Imaging (CD/Films)  Echocardiograms  Pharmacy  Behavioral Health records only  My health information relating only to the following treatment or condition:  My health information only for the following date(s):  Other: REASON FOR REQUEST:  Personal  Transfer of Care  Disability  Insurance  Legal Review  Continuing Care  Other (please explain): I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV)..

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