Records Release TO Other Provider Form

Patient Name:

Patient Address:

City, State, Zip Code:

DOB:

Phone:

RE: Release of medical records for patient:

I authorize Mertz MFM Center to release a copy of all medical records related to my treatment rendered from the period:

From (Date):

Through (Date):

This information will be used to further assist in my medical care. It should be mailed, faxed, or emailed to:

Practice Name:

Provider Name:

Practice Address:

Practice Phone:

Practice Fax:

Practice Email:

Date of Request:

Patient Signature:

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