DAVZ02 Medical Record Release 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
Date
Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Phone Number*
Please enter a valid phone number.
Release Information From:

Davidson Family Medicine

PO BOX 4329 Davidson, NC 28036

Phone: 704.892.5454

Fax: 704.892.5858
Release Information To: *
Name of Facility, person (relationship if person)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Delivery Method

U.S. MailPick UpFax
Purpose of Release (check reason)

Patient RequestLegal PurposeTransferring CareContinued Patient Care
Information Requested

Entire RecordOffice VisitsOffice - Physical ExamOffice - Consultation ReportsOffice - ImmunizationsLaboratory ReportsRadiology ReportsMedicationsBilling informationOther
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 authorization expires 90 days after the date of my signature
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature*

Clear
Name

First NameLast Name
If patient is a minor, are you the parent/guardian?

YesNo
Witness Signature

Clear
Should be Empty: