Medical Records Release Form
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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 #:
________________________________
_______________________ Date_____
Patient Signature
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