Request for release of medical records

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Patient Information

Name

Birth Date

SSN

Address

Phone

Release Records From/To

Office

Address

Phone

Fax

Release the following records to/from: High Risk Pregnancy Doctors

Please Specify

I understand that

Authorizing the disclosure of health information is voluntary. I do not need to sign this form to receive treatment or payment.

I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written notification to my OB/GYN. I understand that the revocation will no apply to information that has already been released in response to the authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

Unless I specify directly, this authorization will expire 12 months from date of signature.