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Medical Records Release

Doctor Information:

Doctor's Name:

Doctor's Email:

Doctor's Phone Number:

Office Address:

Patient Information:

Patient First Name:

Patient Last Name:

Date of Birth:

Phone:

Address:

City, State, Zip:

_____may release the following information:

Entire record
Financial records
 Office visit notes
Dates of service
 Psychotherapy notes – if this box is checked only psychotherapy notes may be released.
Diagnostic studies (list)
 Other as listed

Entity or person who will receive the information:

Name:

Address: