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Patient’s Name Birth date (Please Print) LAST FIRST MI Are medical records filed under another name Phone Number INFORMATION TO BE RELEASED BY: INFORMATION TO BE RELEASED TO: REQUEST MUST HAVE COMPLETE ADDRESS OR FAX NUMBER REQUEST MUST HAVE COMPLETE ADDRESS OR FAX NUMBER Organization/Person Name Organization/Person Name Street Address Street Address City, State, Zip City, State, Zip Phone Phone Fax Fax TYPE OF MEDICAL INFORMATION REQUESTED:  Complete medical record abstract (includes 3 years of chart notes, most recent labs/pathology diagnostic imaging reports)  Cancer Partnership records  Radiology/ Diagnostic Imaging (CD/Films)  Mammogram Diagnostic Imaging (CD/Films)  Echocardiograms  Pharmacy  Behavioral Health records only  My health information relating only to the following treatment or condition:  My health information only for the following date(s):  Other: REASON FOR REQUEST:  Personal  Transfer of Care  Disability  Insurance  Legal Review  Continuing Care  Other (please explain): I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV)..

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Generic Medical Records Release Form

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