Generic Authorization to Release Medical Records Form
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Denton Heart Group
Authorization to Release Medical Records
Name of Patient ________________________________ Date(s) of Service ____________________
Date of Birth ___________________ Social Security Number _______________________
I, the undersigned, authorize the release of, or request access to the information specified below from the
medical record(s) of the above name patient.
PATIENT INFORMATION IS NEEDED FOR:
Continuing Medical Care Military Social Security/Disability
Insurance Personal Use Other: _______________
Legal Purposes School _____________________
INFORMATION TO BE RELEASED OR ACCESSED:
History & Physical Consultation Report Emergency Room Record
Operative Reports Discharge/Death Summary Face Sheet
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