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Washington Medical Records Release Form 1

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This form is provided by The Washington Endocrine Clinic to authorize the disclosure or release of one person's protected health information.

Washington Medical Records Release Form 1
Washington Medical Records Release Form 1
Michael J. West, M.D., Ph.D.
Board Certified in Endocrinology, Diabetes and Metabolism
Donna Westervelt, MS, CRNP, CDE
Diabetologist
Tammy Peng, RD, LD
Registered Dietitian
Medical records release form
This form is to be used to obtain a FULL copy of your entire chart
for yourself or to have medical records transferred or sent to another physician.
Patient's Name ___________________________________________ Patient's Date of Birth: _______________
Patient's address: ____________________________________________________________________________
Person Requesting records and relationship to patient: _______________________________________________
Patient's Phone: ________________________________________
By signing this form, I authorize you to release confidential health information about
_________ _____________________ (Patient), including a full copy of the patient's medical records, or a full
summary/narrative of the patient's protected health information, to the person(s) or entity listed below.
Limitations on the information you may release subjected to this release are as follows:
__________________________________________________________________________________________
Release protected health information to the following person(s)/entity:
(If you are the patient and are releasing these records to yourself only, then please write your name and address
below.)
Your Name or your new doctor's name: __________________________________________________________
Doctor's office name ________________________________________________________________________
Street: ___________________________________________________________________________________
City: _____________________________________ State: ____________ Zip:______________________
Fax: _______________________________________
2440 M Street, NW ▪ Suite 417 Washington, D.C. 20037
Phone 202-570-5151 ▪ Fax 202-446-2946
www.washingtonendocrineclinic.com washingtone[email protected]
HIV/AIDS: I DO q DO NOT q consent to the release of any positive or negative test result for AIDS or
HIV infection, antibodies to AIDS or infection with any other causative agent of AIDS with the rest of my
medical records. Initial: ______________ Date: ______________________________
Washington Medical Records Release Form 1
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