Consent to Release Information

I (print full name)*

Hereby authorize and request medical records be released from: (name of provider / facility)*

Please release a complete copy of medical records, including progress noted, immunizations, labs/x-ray result, hospitalization reports, and previous physical notes. I understand I may revoke this consent at any time and that upon fulfillment of the above stated purpose, this consent will automatically expire. Do not forward requested

information to another person or agency without my consent.

Patient's Signature (type full legal name)*

Date

Please do not submit any Protected Health Information (PHI).

Submit