AUTHORIZATION FOR REQUEST OF MEDICAL RECORDS


To:
Name:
Address:

City/State/Zip:

Telephone:

Fax:


I hereby authorize the release of information from the medical record of:

 Patient Name:   
 Date of Birth: 
 Patient Name:
 Date of Birth: 


Please Release Information To:
Preferred Medical Group: Centralized Fax: (334) 664-0466
Preferred Medical Group Location:





Information Requested:
 




Purpose of Disclosure:
   




Informed Consent for Release of Confidential Information.
I understand that I may revoke this consent in writing at any time except to the extent action has been taken.

I understand that this consent will expire 90 days after the date of my signature unless otherwise specified.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal Privacy Regulations.
 

 Signature of Patient or Legal Representative 
 Date
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Relationship to Patient