Patient InformationPatient First Name(Required) Patient Last Name(Required) Last 4 numbers of Social Security #Maiden or Other Name Patient Address(Required) City(Required) State(Required) Zip Code(Required)Date of Birth(Required) MM slash DD slash YYYY Phone Number(Required)Cell NumberWork numberEmail Release Information FromI hereby authorize the below physician/facility to release my medical records information.Provider Name/Facility(Required) Attention Address City Zip CodePhone Release Information ToProvider Name/ Facility(Required) Attention Address(Required) Phone(Required)City(Required) State(Required) Zip(Required) Fax(Required) Patient Email Address Specific dates of service to be released Records to be released Physician Office Pertinent Transfer Package (standard two years of information) Progress Notes Laboratory / Path Results Radiology Results Immunization Record Other Please be specific, include dates or testing needed By signing I understand that the information in my health records may include information relating to sexually transmitted diseases, acquire immune deficiency syndrome (AIDS), or human immune deficiency virus (HIV). It may also include information about behavior or mental health services, and treatment for alcohol and drug abuse. This consent is valid for 90 days from the date of signature unless revoked by me in writing before release of information as designed above. A copy of this authorization, including the following disclosure statement, will be furnished to whom the information is to be released. This information has been disclosed to you from confidential records from disclosure by state law. You shall make no further disclosure of this information without specific written and informed release of the individual to whom it pertains, or as otherwise permitted by state law. If you are the legally recognized representative of the patient you must provide supporting documentation. This agreement has been signed electronically.Signing Authority(Required) Patient Patient Representative Signature(Required) Today's Date(Required) Month Day Year