Medical Record Authorization Release Form

Patient Name *

First

Last

Date of Birth *

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

MEDICAL RECORDS INFORMATION

I Hereby Request That My Medical Records Be Released To: *

Physician/Clinic's Name

I Hereby Request That My Medical Records Be Released From: *

Physician/Clinic's Name

Be Patient Terms

Address of Medical Facility and/or clinic other then Lifestages

Address Line 1

Address Line 2

City

State

Zip Code

Phone number of other facility

Fax number of other facility

Records to be released: *

All Medical records
Hospital Records/Operative Reports
Laboratory records/Imaging

Medical Records Release Terms & Conditions *

This authorization is valid for 6 months unless revoked in writing earlier. If not otherwise revoked, this authorization will expire in 180 days.

YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

I understand that this authorization extends to all or any part of the records/information designated below, which may include treatment for physical and mental illness and alcohol/drug abuse.
PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Patient or guardian Signature *

Clear Signature

Date *