Records Request Form

Patient Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

First Date of Service for Records Requested:

MM

DD

YYYY

Last Date of Service for Records Requested:

MM

DD

YYYY

Radio

Chart Notes

Intake Forms

Other

Authorization for General Release of Information *

By checking this box, I understand that: - Authorizing the disclosure of this healthcare information is voluntary. - I can cancel this authorization at any time going forward. I understand that once the information has been released according to the terms of this authorization, the information cannot be recalled.

I agree