Release of Medical Recorts

Consent for Release of Medical Records
Today's Date
Your Name

First Name Last Name
Please indicate your doctor’s contact info so we can obtain your medical records. If you are a former patient of Dr. Mintz, you may leave this blank, as we have the information on file.
Doctors' Name and Address

Doctor/Practice Name

Address

City State

Zip Code
Doctor's Fax Number

Area Code Phone Number
Doctor's Phone Number

Area Code Phone Number
Your Name *

First Name Last Name
Your Address *

Your Name

Street Address

City State

Zip Code
Your Date of Birth *

Month Day Year
Date
I am presently a patient of Dr. Matthew Mintz in Bethesda, Maryland and do hereby authorize the release of my medical records
*

Please send all records/all dates Please send records from the selected dates below
From

Month Day Year
Date
To

Month Day Year
Date
Please Sign in the box using your mouse or keyboard touchpad
Please address correspondence to:

                                      Dr. Matthew Mintz

                                      10401 Old Georgetown Rd

                                      Suite 305

                                      Bethesda, MD 20814

                                      Phone and Fax 1-855-646-8963

* This authorization is valid for 90 days from the date of signature.
Should be Empty:

Consent for Release of Medical Records