Medical Records Release Form

Medical Records Release Form

"*" indicates required fields

Name*
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Address*

NAME OF PERSON REQUESTING RECORDS:

Dr. Jeremy Storm, DO | RELATIONSHIP TO PATIENT: Infectious Disease Specialist/Internal Medicine

RECORDS TO BE SENT FROM:

Name
Address

RECORDS TO BE SENT TO:

Name
Address

WHAT INFORMATION IS NEEDED FOR RECORDS REQUEST.

PLEASE CHECK THE APPROPRIATE BOXES*
Other:
Information will be disclosed because of:

Sign & Date

My Signature is approval of my authorization. I authorize the above named Physician and Medical Practice to release my protected health information to those identified on this release. I understand that if any person receives this information that is not covered by the federal privacy regulation, the release may no longer be protected. I understand that my health record may include sensitive and detaled related to STD’s, AIDS, HIV, or mental health services and treatment programs.
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