MEDICAL RECORDS RELEASE
Date _____________________________________________________________________
Patient Name ______________________________________________________________
Patient Address ____________________________________________________________
Name at time of service ______________________________________________________
Soc. Sec. # _______________________________________________________________
Date of birth ______________________________________________________________
REQUESTED FROM:
Physician Name ____________________________________________________________
Address __________________________________________________________________
__________________________________________________________________
Phone # ________________________________ Fax # _____________________________
I hereby authorize you to release my records to:
Any pertinent information including the diagnosis and records of any treatment or examination rendered to me during the period from __________to____________.
__________________________________ _____________________________________
Signature Witness
__________________________________ _____________________________________
Date Date
Commercial F3--medical release rev 6 JLL 050506 Alison A. Clarey, D. O., Inc. www.daytonbariatriccenter.com