Tennessee Medical Records Release Form 2
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TENNESSEE CONSOLIDATED RETIREMENT SYSTEM
502 Deaderick Street
Nashville, Tennessee 37243-0201
(615) 741-1971

MEDICAL RECORDS RELEASE AUTHORIZATION
I hereby authorize the following healthcare provider(s) and its physicians, employees and agents to release or disclose to the Tennessee
Consolidated Retirement System (TCRS) and its representatives all of my medical records including records pertaining to treatment, prognosis
and diagnosis, including any specially protected or listed records, such as those relating to psychological or psychiatric impairments, drug
abuse, alcoholism, sickle cell anemia, or HIV infection. (Please list at least one healthcare provider. If you have more than three, please list them
on another form.)
Healthcare Provider

Address

Phone Number

_______________________________

_________________________________________________________

____________________

_______________________________

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