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

• Medical consultation for specialist referral

Records to be Released

• Medical History, Lab Results, Imaging Reports

• Date Range of Records: 01/01/2080 TO 12/31/2087

Method of Release

• Records to be provided via email and secure portal

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

• Signature: Elisa West

• Date: 11/28/2088

• If signed by Legal Representative:

  • Relationship to Patient: N/A

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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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