Medical Records Release Medical Records Release Form Please complete the form below or download the pdf and fax the document to 480-949-2091. DOWNLOAD PDF >> Patient's Full Name*Date of Birth* MM DD YYYY TO:Name (or title) and OrganizationAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFAXEmail Please disclose the following information (check all that apply): All of my health information including, but not limited to, AIDS/HIV and other communicable disease information, Behavioral Health Care/Psychiatric Care, Alcohol and/or Drug Abuse Treatment, unless specifically excepted, My health information relating only to the following treatment or condition: Treatment or Condition (if checked above): My health information for the following date(s) of service: Date(s) of service (if checked above) Other (specify) If other, please specify:You may disclose the health information to:Name (or title) and OrganizationAddress of above organization* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFAXEmail Consent* Ok to fax medical records. (This document is confidential, intended for named recipient only.)The signature below authorizes the release of my medical records as checked above. A copy of this signature form is as valid as original.SignatureDate* Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Skip back to navigation