Transcription of PATIENT INFORMATION RELEASE AUTHORIZATION …
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PATIENT INFORMATION RELEASE AUTHORIZATION …
PATIENT INFORMATION RELEASE AUTHORIZATION Fill in the appropriate INFORMATION in each applicable section. Sign and date the form. Incomplete forms will be returned to you unprocessed. A separate AUTHORIZATION must be completed for each request. INSTRUCTIONS PATIENT Full Name: _____ Last First Initial Date of Birth: _____ Last 4 Digits of SS# _____ Sex: M / F Telephone: (_____) _____ Address: Street: _____ City: _____ State: _____ Zip.
Frequently Asked Questions – Medical Records . Incomplete forms will be returned to you unprocessed. A separate authorization must be completed for each request.
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