Generic Authorization to Release Medical Records Form
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Denton Heart Group
Authorization to Release Medical Records
Name of Patient ________________________________
Date of Birth ___________________

Date(s) of Service ____________________

Social Security Number _______________________

I, the undersigned, authorize the release of, or request access to the information specified below from the
medical record(s) of the above name patient.

PATIENT INFORMATION IS NEEDED FOR:
Continuing Medical Care
Insurance
Legal Purposes

Military
Personal Use
School

Social Security/Disability
Other: _______________
_____________________

INFORMATION TO BE RELEASED OR ACCESSED:
History & Physical
Operative Reports
Lab/Path Reports

Consultation Report
Discharge/Death Summary
X-Ray Reports/Images

Emergency Room Record
Face Sheet
Other: ________________

The above information may be released (specify name or title of the individual or the name of the organization to which
records are to be released and the appropriate address):

TO:
________________________