Medical Records Release Form Request To Obtain Records From Another Doctor Or Hospital printable pdf download

Medical Records Release Form Request To Obtain Records From Another Doctor Or Hospital

3820 S. Hualapai Way #200

Dr. Frank Nemec

Las Vegas, NV 89147

Dr. Donald Kwok

(702) 796-0231

Dr. Gregory Kwok

Fax (702)796-5211

Dr. Brent Burnette

Medical Records Release Form

Request to obtain records from another Doctor or Hospital

TO: ___________________________________________________________________________

______________________________________________________________________________

(DOCTOR OR HOSPITAL)

I HEREBY AUTHORIZE YOU TO RELEASE ANY/ALL MEDICAL RECORDS TO:

GASTROENTEROLOGY ASSOCIATES

3820 S. HUALAPAI WAY #200

LAS VEGAS, NV 89147

(702) 796-0231

PLEASE SEND THE COMPLETE MEDICAL RECORDS CONCERNING MY ILLNESS AND TREATMENT DURING

THE PERIOD OF

FROM:__________________________________ TO:_________________________________

PRINT PATIENTS NAME: _______________________________

SIGNED: ___________________________________________

(PATIENT OR LEGAL GUARDIAN)

ADDRESS: ____________________________________________

DOB: _________________________________________

SS#:__________________________________________

WITNESS:________________________________

DATE:_________________________________

Medical Records Release Form Request To Obtain Records From Another Doctor Or Hospital