Date:____________

To (Medical Provider): _____________________________________________________

Address: ______________________________________________________________

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Phone #:_______________________________________________________

I hereby authorize and request you to release to:

the complete medical records in your possession concerning my illness and/or treatment during
the period from _________________________ to _________________________ .

Thank you.


Signed: _______________________________________ (Patient or legal guardian)

Print Patient's Legal Name: ________________________________________________

Relationship (if legal guardian): ____________________________________________

Patient's Address: ________________________________________________________

_______________________________________________________________________

Phone #:(______) ________________________________________________________

E-Mail: ________________________________________________________________



Witness: _______________________________________________________________