Medical Record Transfer Form

Medical Records Release

Use this form to authorize the release of some or all of your personal medical records and information either:

Fill in your current information below. Please fill out all required* fields so we may properly identify you and the intended recipient. Use the "Format" button below to review and print the completed form.

from third parties to Dr. Tanenbaum or,

from Dr. Tanenbaum to others.

Patient Information:

First Name*	Middle		Last name*
Date of Birth:* mm/dd/yyyy		Home Phone:* xxx-xxx-xxxx
Gender:*		Social Security Number:* xxx-xx-xxxx

Release Information From: Select One:*

Dr. Tanenbaum Third Party**

**Please fill in third party information as completely as possible.

Physician, Clinic, Hospital, Company or other Name:*

Street Address:

Street Address:

City: State: Zip:

Contact Name:

Contact Phone: Ext: FAX:

Other Contact Info:

Release Information To: Select One:*

Dr. Tanenbaum Third Party**

**Please fill in third party information as completely as possible.

Physician, Clinic, Hospital, Company or other Name:

Street Address:

Street Address:

City: State: Zip:

Contact Name:

Contact Phone: Ext: FAX:

Other Contact Info:

Information Requested: Select One*

All office records

History & Physical, discharge summary & operative reports

Outpatient & ER visits

Visits limited to a specific treatment or condition:

Use these areas to further define records of
Treatment or Condition:
Other:
Include records dated From: To: (mm/dd/yyyy)

Terms and Conditions:

I request and authorize the above named "from" party to release the specified information to the above named "to" party.

I understand that the information to be released may include information regarding the following: Drug abuse, Sickle Cell Anemia, alcoholism or alcohol abuse, psychological or psychiatric conditions or other sensitive data, if any conditions exist.

I understand that I may revoke this authorization at any time, except to the extent that action has already been taken. Without my express revocation, this consent will expire in 90 days from the date of my signature.

I hereby release my attending physician from all liability and all claims of any nature whatsoever, pertaining to the disclosure of the information contained in my records as described above.

I have read this form and fully understand the conditions listed above and I certify that the information provided is accurate and correct. Accepted by entering your full name below:

Signature of Patient/Legal Guardian:*

Check Results and Print:

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