Medical Record Release Medical Record Release AUTHORIZATION TO RELEASE HEALTHCARE INFORMATIONPatient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Phone NumberRecords Being Sent To(Required) Facility or Provider Name: Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Records Being Requested From Facility or Provider Name: Address City North CarolinaAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFaxInformation Being Requested Office Visit Notes Laboratory Test Results Radiology Report (includes x-ray, MRI, CT, bone destiny scan, etc.) Entire Record Record related to the following conditions or events: Records within a specific time frame (examples: 2017 – present, most recent, or last 3 visits:) ConditionsTimeframesConsent(Required) By checking this, I understand that I am authorizing the use and/or disclosure of the patient’s protected health information as described in this document.** Copying Fees: $0.75 per pg. (1-25), $0.50 per pg (26-50) and $0.35 per pg (51+) **