Authorization to Release Medical Records I hereby authorize _________ to receive a copy of all my clinical records including but not limited to CT reports, Ultrasound Reports, Lab Results, Colonoscopy OP Report, EGD Report, Pathology / Biopsy Results, and HIV test results to * Enter third party's name Name * First Name Last Name Last 4 of Social: * Date of Birth: * MM DD YYYY Patients Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Patient Disclaimer and Authorization * By checking this box, I certify that I am the patient or the patient’s authorized representative, and I hereby request the release of the medical records specified above. I understand that checking this box serves as my electronic signature and is legally binding, just as if I had physically signed this form. Thank you!
