Medical Record Release
Patient Information
Full Name: Elisa West
Date of Birth: 05/15/2050
Address: Chula Vista, CA 91909
Phone Number: 222 555 7777
Email Address: elisa@you.mail
Recipient of Information
Healthcare Provider/Organization Name: California Medical Group
Address: Chula Vista, CA 91909
Phone Number: 222 555 7777
Release of Information
I, Elisa West, hereby authorize [YOUR COMPANY NAME] or any of its representatives to release my medical records and related information as outlined below.
Purpose of Disclosure
Records to be Released
Medical History, Lab Results, Imaging Reports
Date Range of Records: 01/01/2080 TO 12/31/2087
Method of Release
Expiration of Authorization
This authorization will expire on 12/31/2088, unless revoked earlier by written notice from me.
Revocation of Authorization
I understand that I may revoke this authorization at any time by notifying [YOUR COMPANY NAME] in writing, but the revocation will not affect any disclosures made prior to the revocation.
Right to Refuse
I understand that I am not required to sign this authorization, and that treatment, payment, or enrollment in health benefits will not be affected by my decision to sign or not sign this form.
Acknowledgement of Receipt
I acknowledge that I have received a copy of this release form for my records.
Signature of Patient or Legal Representative
For Office Use Only
Records Released By: [YOUR NAME], Medical Records Coordinator
Date Released: 11/29/2088
Method of Release: Secure email portal
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