Medical Release Form

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

All sections must be completed!

Note: If you have multiple doctors, please fill out form for each doctor.

I hereby authorize the medical office named below (your doctor’s name and doctor’s phone/fax number) and its providers, employees and agents to release or disclose to the below-named recipient all of my medical records including any specially protected records such as those relating to psychological or psychiatric impairments, drug abuse, alcoholism, sickle cell anemia, sexually transmitted disease, or HIV/AIDS infection.

Medical Office Name
Provider Name and Address
Provider Phone
Provider Fax

Patient Name
Patient Home Telephone
Patient Cell Telephone
Date of Birth

I hereby authorize the release of medical records to: Precision Pain Care PLLC

Purpose of disclosure : Continuation of care

The authorization will expire on

This request and authorization applies to:

Medical Records
Imaging
Urinalysis
Discharge Letter

Describe the health care information or records relating to the following treatment, condition, or dates of treatment:

Specific records to be released (e.g., labs, imaging reports, other):

If you DO NOT WANT certain portions of your medical records released, please initial the box for the information you do not want released.

Substance abuse
Psychological or psychiatric treatment
HIV/AIDS/STD

I understand I have a right to revoke this authorization by written notification to the Privacy Officer, except to the extent it has acted in reliance thereon before notice of revocation. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure which may not be protected by federal confidentiality rules. I understand that I may request a copy of this authorization. I understand that I can refuse to sign this authorization and the above-named office may not condition treatment on my signing of this authorization.

Signature of Patient or Authorized Representative

Redo Signature

Date Signed
Relationship to Patient