Phone #: (954)969-9002 Fax #: (954)345-7888

Consent to Release Patients Record's

 

Please complete and print out the below mentioned form before submiting it to your physician.

 

I hereby request that the medical
  (Authorizing Individual)
record of be released to:
  (Patients Name)

 

 

Name:
Address:
City
State
Zip Code:
Phone Number: Fax Number:

These Records are to be:

  Mailed
  Faxed
  Information Phoned
  Hand picked by

 

Note:

The first set of records are free, but a prepaid charge will be required for copies requested thereafter. With this in mind, if you expect to need additional copies, you may want to reproduce these records for your personal medical file.

 

I want this to be considered my free set.
Please bill and await payment from the below party before copying:
I will provide the prepaid copying fee when Informed of the extra cost.

 

 
 

Signature of patient or legal

Date:  
  guardian if minor
  Witness Date: