DAVZ02 Medical Record Request Form

Authorization for Use and/or Release of Medical Records

Patient Information: I give permission to release the health information of:
Patient Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Release Information From:
Name of the Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Release Information To:
Davidson Family Medicine P.O. Box 4329 Davidson, NC 28036
Phone: 704.892.5454 Fax: 704.892.5858

PLEASE DO NOT SEND ANY RECORDS ON A CD
Purpose of Release (check reason)

Other-Specify
Information Requested

Other-Specify
I understand that:

If these records contain any information about HIV/Aids status, cancer diagnosis, drug-alcohol abuse, or sexually transmitted diseases, I am hereby authorizing disclosure of this information.

This permission expires 90 days after the date of my signature
Digital Signature Authorization:
Signature
Printed Name

First NameMiddle NameLast Name
If patient is a minor, are you the parent/guardian?
Should be Empty: