Release of Medical Information

Release of Medical Information:

Download the Release of Medical Information form here.  

Please fill out all highlighted sections, including:

1. Patient’s Name, Date of Birth, Address and Phone Number
2. Facility Authorized to Release Information to:
   • Records Released to you - write in “SELF"
   • Records Released to another Provider or Facility - please fill in the Providers name, address, phone and FAX number. 
   • Health Information to be disclosed - include all dates of service, what type of records you want released (labs, x-ray, complete, etc.), why you need the information (treatment, insurance, personal),
3. The Yes/No question is an authorization to release any sensitive information. Typically this should be marked yes if you require all of your information to be released.
4. Patient’s or Authorized Personal Representative’s Signature – please sign, date and time.
5. Leave the Witness Signature line and everything below it blank.
   

Please return to us via fax at 858-244-3524. If you have any questions, please call 618-241-8547.