Read Patient Release of Medical Records Form text version

Patient Release of Medical Records Form

Patient Release of Medical Records Form (Please Print or Type)

Patient's Name:_____________________ request and give my permission to release my Medical Records for the time period dating from_____________ to ____________ from the following Medical Clinic: M.M.P.E. Medical Clinic Dr. R. Stephen Ellis, M.D. 450 Sutter St. , Suite 1415 San Francisco, CA 94108 Office Phone (415) 681-0823 The Medical Records as listed above are to be released to: Name:____________________________________________ Address:__________________________________________ City_______________________State___________zip_____ Phone Number:____________________________________ Fax Number:_______________________________________

Comments________________________________________ _________________________________________________ If Faxing or mailing the Release of Medical Records Form to the Medical Clinic, include a copy of a photo ID such as a State issued Driver's License, State Issued ID Card, or Passport. Type of ID Presented:____________________ ID #___________________ _____________________________ Printed Patient Name _____________________________ Patient's Signature ___________ Date of Birth ______________ Social Security #

____________________________ Today's Date

file:///C|/Documents and Settings/Michael Sullivan/Desktop/Medical Release.htm9/1/2005 8:52:26 PM

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Patient Release of Medical Records Form

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