MEDICAL RECORD RELEASE AUTHORIZATIONName 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 faxReferring physician name First Last Referring physician address Street Address City State / Province / Region ZIP / Postal Code Patient’s signatureDate MM slash DD slash YYYY For office use ToPhoneFaxPhoneThis field is for validation purposes and should be left unchanged.
