RECORD RELEASE FORM - Dept Ford Medical Center

I authorize the release of my medical records by the organization or Physician listed below.

PHYSICIAN’S NAME

PHYSICIAN’S PHONE NUMBER:

PHYSICIAN’S ADDRESS:

Address Line 1

Address Line 2

City

State

Zip Code

FAX NUMBER

REASON FOR RECORD RELEASE

These records are to be sent to DEPTFORD MEDICAL CENTER - FAX NUMBER: 856-848-8038

PATIENTS NAME: *

First

Last

DOB

ADDRESS

Address Line 1

Address Line 2

City

State

Zip Code

PHONE NUMBER

The type and amount of information to be disclosed to be initiated as follows: (specify date where appropriate)

Entire Medical Records
Immunization Records

Other

I understand this authorization will expire, without my revocation, one year from this date of signing, or if I am a minor on the date; I become an adult according to the state law. I understand that I may revoke this authorization or to my insurance company. I understand that any discourse and the information may not be protected by the federal Confidentiality rules. I accept full financial responsibility of any copying or shipping fees and any applicable sales tax that may be charged.

Date

PRINTED NAME *

Signature

RELATIONSHIP TO PATIENT

1132 Cooper St, Deptford, NJ 08096, United States

DeptFord Medical Center