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Medical Records Release Form

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Medical Records Release Form Template

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Medical Records Release Form

Patients Name: ___________________________________________

I do hereby request and give permission to release my Medical Records for the following time period:

____/____/______ - ____/____/______

From the following Medical Clinic:

Name: ____________________________________________________

Address: _________________________________________________

City: __________________________________________ State: ______ Zip: ____________

Office Phone: __________________________________________

Please Release the above mentioned Medical Records to:

Name: __________________________________________________

Address: _______________________________________________

City: __________________________________________ State: ______ Zip: ________________

Office Phone: ___________________________________________

Please include a copy of ID:

Type of ID presented: ___________________________________

ID #: ___________________________________________________

Printed Patient Name: ___________________________________

Date of Birth: ____/____/______ Social Security #: ___________________

Patient Signature

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