Free Medical Release Form 13
Download the document to the computer for easy use
There are more pages to preview,Read on

MEDICAL RECORDS RELEASE FORM
To:
Physician Name: __________________ Pt Name: ___________________DOB________
Fax #:___________________________ Pt. MCA Acct #:____________________
Portions of Record Needed-----Check Applicable Sections
� Discharge Summary FAX REQUESTED RECORDS TO 334-280-1600
� History & Physical ATTN: MEDICAL RECORDS
� Operative Rpt
� ER Record
� Stress Test Rpt
� Chest X-Ray
� Echo Report
� EKG/Stress Strips
� Holter/Event Monitor
� Lab Work
� Physician’s Progress Notes
� Physician’s Orders
� Other:_______________
Treatment Dates requested: _________________
Information about you is protected under federal law and you have the right to revoke this Authorization
except to the extent that we have taken action in reliance on your Authorization. Please contact the MCA
Medical Records Department for an “Authorization Revocation” form if one is needed. By signing below,
you recognize that the protected health information used or disclosed pursuant to this Authorization may
b