Patient Release Form - PDF by pft20924

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									 Patient Release of Medical Records Form



                                            Patient Release of Medical Records Form
                                                      (Please Print or Type)


Patient's Name:_____________________ request and give my permission to release my Medical
Records for the time period dating from_____________ to ____________ from the following
Medical Clinic:

                                                        M.M.P.E. Medical Clinic
                                                       Dr. R. Stephen Ellis, M.D.
                                                       450 Sutter St. , Suite 1415
                                                        San Francisco, CA 94108
                                                       Office Phone (415) 681-0823

                                The Medical Records as listed above are to be released to:

                                Name:____________________________________________

                                Address:__________________________________________

                                City_______________________State___________zip_____

                                Phone Number:____________________________________

                                Fax Number:_______________________________________


                                Comments________________________________________

                                 _________________________________________________

                     If Faxing or mailing the Release of Medical Records Form to the Medical
                         Clinic, include a copy of a photo ID such as a State issued Driver's
                                      License, State Issued ID Card, or Passport.

                      Type of ID Presented:____________________ ID #___________________

                     _____________________________                                ___________        ______________
                    Printed Patient Name                                          Date of Birth       Social Security #

                     _____________________________                                ____________________________
                           Patient’s Signature                                             Today's Date




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