Medical Records Release Form

I , hereby authorize:

Name of Facility or Provider: (Who we are requesting from)

Address:

City:

State:

Zip:

Phone:

Fax:

To Release Medical Records to Legacy Partners for Equitable Healthcare, PLLC at the address or fax number listed above.

Patient Name:

DOB:

Please send the following medical information checked below:

□ All Medical Records

□ Progress Notes

□ Labs, X Rays, MRI's etc...

□ Other:

This consent is subject to revocation by: or at any time. This Authorization will expire in six months from the date signed below.

Print Patient Name or Patient's Representative

Relationship

Signature of Patient or Representative of Patient

Today's Date