Medical Record Release Form

Please complete the online Medical Record Release Form. Required fields are identified with an "*" in the field name. If you prefer to print out a copy and bring it to the office, please use the link in these instructions.

Medical Record Release Form

All information is encrypted

Select your Primary Office:

Charlotte Hall Office

Waldorf Office

Patient's First Name:

Patient's Last Name:

I authorize the release of information to:

Name of authorized individuals:

Please provide the Name, Phone Number and E-Mail address of the people you want your medical records released to.

Health information to be disclosed upon the request of the person named above (check box below):

Disclose my complete health record (including but not limited to diagnosis, lab tests, prognosis and biling for all condidtions.

OR

Disclose my health records, as below, BUT do not disclose the following (Check as appropriate).

Multi choice

Mental health records

Communicable diseases (including HIV and AIDS)

Alcohol/Drug abuse treatment

Other

Form of disclosure (unless another format is mutually agreed upon between my provider and designee):

Electronic record or access through an online portal

Printed Copy

Other

This authorization shall be effective for all past, present or future times unless specified or revoked:

Other Date of Expiration:

NOTE: You may revoke this authorization in writing at any time by notifying your healthcare providers,

preferably in writing.

Name of the person giving this authorization:

Relationship if not Self:

Date of Authorization:

Signature:

Signature field is empty.

Date of Signature

Return to the Patient Registration Page

Please note: that you must submit the form to save any information. Leaving the page will not save any of your insurance information.

Medical Record Release Form

Medical Record Release Form

OR

Medical Record Release Form

OR

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