Patient Information Release Form (Records Release)

Patient Information Release Form

Authorization for Release of Confidential Information: Please allow 24-48 Business hours to process. There will be a fee or records. In the case of a extensive file, fees made be added.
Fields with an asterisk (*) are required.
Today's date: *

Month Day Year
Doctor: *

John C. Burnside M.D. Kristeen R. Spratley M.D. William Lee M.D. Louise O'Donnell Ph.D
Patient's full name: *

First Name Last Name
Patient's age: *
Patient's birthdate: *

Month Day Year
I hereby give my permission for
to receive and / or disclose any confidential information, verbal or written, regarding the above named patient to include :
Specify what information to be included ; If all records state ALL
Information to be released to:
Please provide the contact information of the person that records are being released to including fax number
I understand that the information obtained will be treated in a professional and confidential manner and will not be disclosed to any other person or agency without the written consent of the above named person or parent/guardian. This consent expires ninety (90) days from the initialed date below.
Patient or parent/guardian initials: *
Contact name: *

First Name Last Name
Contact phone: *

Area Code Phone Number
Contact email: *
Should be Empty: