MEDICAL RECORDS RELEASE FORM

PATIENT INFORMATION

Patient Name:

Chart Number:

Address:

Phone:

Date of Birth:

SSN: XXX - XX -

CONSENT TO RELEASE RECORDS

I do hereby consent and authorize Family Medical Center of Rocky Mount to release copies of my medical records.

Name of Person or Facility to Receive Records :

Address :

Phone :

Fax :

E-mail :

CONSENT TO OBTAIN RECORDS

I do hereby consent and authorize Family Medical Center of Rocky Mount to obtain copies of my medical records

Name of Person or Facility to Receive Records :

Address :

Phone :

Fax :

E-mail :

Please indicate date(s) or specific records to be released :

Please select how you would like the records to be released:

Delivery Preference :

Format :