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Medical Records Release

Authorize the transfer of your medical records to or from another provider.

Patient Information

Patient Full Name*

Date of Birth*

Phone*

Address

Release Records From

The facility or provider that currently holds your records.

Facility / Provider Name*

Address

Phone

Fax

Send Records To

Pre-filled with our office information. Edit if sending elsewhere.

Facility Name*

Address*

Phone*

Fax*

Records Requested

Select the types of records you are requesting.

Date Range From

Date Range To

Purpose of Release*

Authorization & Signature

I authorize the release of the medical records specified above. I understand that I may revoke this authorization at any time by providing written notice to the releasing facility.

This authorization expires one year from the date of signature unless otherwise specified. I understand that once the information is disclosed, it may no longer be protected by federal privacy regulations.

Signature *

Draw your signature above using mouse or touch

Date: 3/25/2026