Request to Release Medical Records I hereby request Dr. * To release and or all clinical records including * Office Notes Procedure Reports Pathology / Biopsy Results Imaging Results Lab Work Results For my own personal records: * 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 Return records to fax number: * 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!
