Tennessee Medical Release Form 3
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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
PATIENT NAME: _________________________ DATE OF BIRTH: ____________________
DATE OF ACCIDENT: ____________________ S. S. NO.: ___________________________
THE FOLLOWING HEALTH PROVIDER IS AUTHORIZED TO PROVIDE MEDICAL RECORDS AND DISCLOSE PATIENT IDENTIFIABLE HEALTH
INFORMATION:

NAME: _________________________________

PHONE: ____________________________

ADDRESS: ______________________________ FAX: ______________________________
The above named health provider is authorized to discuss my medical treatment and health information with FISHER LAW GROUP,
PLLC – CHATTANOOGA herein after referred to as DONALD W. FISHER & ASSOCIATES and named health provider is NOT
authorized to discuss my medical treatment or health information with ______________________________ Insurance Company.
The scope of the Protected Health Information (PHI) to provided or disclosed is as follows: All medical records for all dates of service
for all medical conditions