Free Medical Release Form 04Free Medical Release Form 04
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MIDLANDS ORTHOPAEDICS, P. A. (MOPA)
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Print Patient’s Full Name ____________________________Birth Date__________ (Mo/Day/Yr)
____________________________________________________________________________
Street Address Social Security Number
____________________________________________________________________________
City, State, Zip Code Phone (Home)

At the request of the individual, I ____________________, do hereby authorize
MOPA to release:
____________________________________________________________________________
(Patient’s Name)

DATES OF SERVICE:
____________________________________________________________
__DISCHARGE SUMMARY
__HISTORY & PHYSICAL
__PROGRESS NOTES
__OPERATIVE NOTES

__I do __I do not
__PATHOLOGY REPORTS __EMERGENCY REPORTS
__LABORATORY REPORTS __OTHER _________________________
__RADIOLOGY REPORTS
__ECG/EEG/CARIAC CATH

authorize the release of information related to AIDS (Acquired Immunodeficiency
Syndrome) or HIV