Authorization for release of Medical records.pdf

Original file name: Authorization for release of Medical records.pdf
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Authorization for Release of Medical Records I hereby authorize the release of my medical or copies of same from: Aptos Women’s Health 3275 Aptos Rancho Rd. Suite E Aptos, CA 95003 Fax: 831-688-0811 Phone: 831-688-8266 To:____________________________ Doctor, Hospital, or Self Address:_______________________ ______________________________ Phone:________________________ Fax:___________________________ Of my Medical records, please Provide: □ Medical overview: Medical Health Summary along with records since Dec 2012 (complimentary if sent to a medical provider, $20 charge for patient pick-up) □ My archived paper chart, after it has been scanned into Epic. (complimentary, will be available for office pick-up first week of October) □ Only The following portion of my medical records: ____________________________________________________________ I agree to pay a reasonable cost to cover this service. Signature:_________________________________ Date:____________ Patient name:_______________________________________________________ Other names records might be under:____________________________________ Address:___________________________________________________________ Phone #:(___)____-______ Date of Birth:____/____/____ Social security#:____-___-_____

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