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Records Requested From:

Patient Name:

Date Of Birth:

Month: Day: Year:

Social Security Number:

Signature of Patient
(Use your mouse cursor to sign your name.
Click in the box to the right and hold down the mouse button and drag your mouse cursor to sign your name. Release the mouse button when you're done signing your name.)

I certify that this is my signature (please type your full name)

Information to be released:

History / Physical	Progress notes	Discharge Summary
Consultation	Operative Report	Cardiac Cath. Report
Treadmill Test	EKG / ECG	Holter / Event
Lab Reports	Chest X-Rays	Monitor
Echocardiogram	Nuclear Scans	Radiology
Polysomnogram	Electrophysiology Procedures	Vascular Report

I hereby authorize the release of any protected health information from my medical record which Cardiac Clinic deems necessary for my cardiology care. I understand that information disclosed may contain information on testing, diagnosis, and/or treatment for HIV, AIDS, sexually transmitted diseases, psychiatric disorder/mental, or drug and/or alcohol use. I understand that this authorization is voluntary and I may refuse to sign this authorization. I understand that my receiving treatment with Cardiac Clinic will not be affected by my refusal to sign this form.