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Consent To Release or Obtain Medical Information
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Your First Name
*
Your answer
Your Last Name
*
Your answer
Your Date of Birth
*
Your answer
Do you want us to:
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SHARE YOUR MEDICAL INFORMATION with a family member, loved one, caretaker, etc?
SEND YOUR MEDICAL RECORDS to another provider or facility
OBTAIN YOUR MEDICAL RECORDS from another provider or facility
SHARE YOUR MEDICAL INFORMATION
If you want a family member, caretaker, loved one to have access to your medical records, please list their full name(s) below.
Your answer
SEND YOUR MEDICAL RECORDS
If you want us to send your medical records to a different clinic or provider, please provide the information below.
Name of Provider or Clinic (Release)
Your answer
Phone number of Provider or Clinic (Release)
Your answer
Fax number of Provider or Clinic (Release)
Your answer
OBTAIN YOUR MEDICAL RECORDS
If we need to obtain your medical records from a different clinic or provider, please provide the information below.
Name of Provider or Clinic (Obtain)
Your answer
Phone number of Provider or Clinic (Obtain)
Your answer
Fax number of Provider or Clinic (Obtain)
Your answer
This Release is Valid Indefinitely
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Yes
No
If no, Start Date
Your answer
If no, End Date
Your answer
I hereby authorize Hidden Valley Family Medicine to release or obtain my medical records to the person or entities listed for the amount of time specified.
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Yes
No
Please type your full name as eSignature
*
Your answer
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