Medical Records Release Form
William P. Cooney, M.D.
Robert E. FitzGibbons, M.D.
Matthew R. Gerlach, M.D.
Gregg A. Koldenhoven, M.D.
Curtis L. Leonard, M.D.
Timothy J. Pater, M.D.
Gerald R. Rupp, M.D.
Samuel E. Smith, M.D.
Jenna Cappello, PA-C
Eric Crouch, PA-C
I hereby authorize the use or disclosure of health information from the medical record of:
Patient Name ______________________________________________________________
Date of Birth _____/_____/_____
Best Contact telephone #_____________________
I authorize FROC, P.C. to release confidential health information about me, by releasing a
copy of my medical records, a summary or narrative of my protected health information, or
verbally to the individual or organization listed below.
Specific Description of the Information to be released:
__ Progress Notes
__ Radiology films
__ Other______________________ __ Diagnostic study reports (labs, radiology, etc.)
___________________________ __ Outside records (hospital, thera