MEDICAL RECORD RELEASE AUTHORIZATION

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MEDICAL RECORD RELEASE AUTHORIZATION

Name

First Last

I authorize you to furnish a copy of my medical records to Dr. Julie A. Lorber, PC. I release you from all legal responsibility or liability that may arise from this authorization.
This authorization also includes consent to fax the above records, if necessary to:

Primary physician name

First Last

Primary physician address

Street Address City State / Province / Region ZIP / Postal Code

Primary physician fax

Referring physician name

First Last

Referring physician address

Street Address City State / Province / Region ZIP / Postal Code

Patient’s signature

Date

For office use

Phone

Fax