Authorization of Release of Medical Records Form

Authorization of Release of Medical Records Form – Rockford, IL

Before submitting this form, please call the front desk, so they are able to give you the correct record number that needs to be entered. This form will not be accepted electronically, if it does not include the correct record number.

Patient Record Number - Please see note at top of form.

Date

Patient Full Name

DOB

Patient Address

City

State

Zip

Phone

Email

I, (name entered below), hereby voluntarily authorize the disclosure of information from my health record

Information Requested

Purpose of Release

The information is to be provided to:

Name of Person/Organization

Address

City

State

Zip

Phone

Fax

Notes

Authorization

By clicking this box and entering your name below, you are certifying that you give legal permission to release your records as requested above

Patient/Guardian Name (signature)

This information is to be released for the purpose stated above and may not be used by recipient for any other purpose