Internal Medicine Specialist of Frederick, LLC
Dr. Tyra D. Kane
85 Thomas Johnson Court
Frederick, MD 21702
301-668-9393 Fax 301-668-4480
RELEASE OF INFORMATION REQUEST
I authorize the release of the following records from: ____________________________________________________________
____ History & Physical ____ All consultant’s reports ____ All lab data/path reports
____ Office records ____ Operative/Procedure reports ____All x-ray/ultrasound/nuclear reports
Records regarding:
_______________________________________________________________________________________________________
The purpose of the release of this information is (if releasing records FROM this practice):
____ Transfer of care: leaving this practice; effective date _______________________________________________________
____ Transfer of care due to insurance change or leaving this area; effective date ____________________________________
____ Legal: injury or worker’s compensation ____ Legal: other, please specify ____________________________________
____Other, please specify _________________________________________________________________________________
THE MEDICAL RECORDS RELEASED MAY CONTAIN INFORMATION PRETAINING TO PHYCHIATRIC, HIV (AIDS), SEXUALLY
TRANSMITTED DISEASES, DRUG AND/OR ALCOHOL DIAGNOSIS AND TREATMENT. I RELEASE THE DOCTORS, AGENTS, AND
EMPLOYEES FROM ALL LEGAL RESPONSIBILITY OR LIABILITY FOR ANY ACTIONS OR OMISSIONS THAT MAY RESULT FROM THIS
AUTHORIZATION. A COPY OR FACSIMILE OF THIS FORM SHALL BE AS VALID AS THE ORIGINIAL.
This authorization is valid for one (1) year. Please fax reply 301-668-4480 YES/NO
(printed name)__________________________________________________________________________________________
(signature)_____________________________________________________________________________________________
(date of birth)_____________________ (last four of ss#)__________________________ (date signed) __________________
Maryland law, Health-General Article section 4-304(c)(3), as of 2007 allows: preparation fee of not more than $21.00, plus 69c
per page, plus cost of mailing.