Florida Medical Records Release Form 2Florida Medical Records Release Form 2
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MEDICAL RECORDS RELEASE FORM (Patient access of medical information)

1of 2

M.R. #
PATIENT NAME
DATE OF BIRTH

S.S. #

ADDRESS/STREET/APT
CITY, STATE, ZIP CODE

TELEPHONE #

I hereby authorize the Medical Records Department staff at to release information from my medical record
to: (If self please indicate below)
NAME
ADDRESS/STREET/APT
CITY, STATE, ZIP CODE

TELEPHONE #

For the purpose of: (please check one)

o Continued Treatment
o Other

o Legal Review

o Insurance purpose

o Personal review of information

(please specify)

I limit the information to be released to the following items: (Please check specific items)

o Discharge Summary

o Consultation

o Emergency Department Record
o Diagnostic test

o Other

o Pathology Report

o Operative Note

(please specify)

(e.g. Lab, X-ray, Radiology)(please specify)

o Outpatient Record

(please specify)

Covering records from on or about (Date)

to (Date)

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