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Medical
Record Release Form
Please cut and paste this form into a word processor
for printing, or if this is not possible then print this Webpage.
You should then complete the form and mail signed copies to the
appropriate person(s)/organization(s) and me.
Or, download the release form directly in Word or text formats:
Release Form.TXT Release
Form.DOC
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Specific information to be released:
[] Verbal/Telephone/e-mail contact
[] Summary of Treatment
[] Office Notes
[] Reports from labs or other outside studies
[] Other___________________________________________________
[] I hereby authorize the following person(s)
and/or organization(s) to release the above information to:
David L. Nathan, M.D.
601 Ewing Street, Suite C-10
Princeton, New Jersey 08540
Phone: (609) 688-0400
Fax: (609) 688-0401AND/OR
[] I hereby authorize Dr. Nathan to release the above information
to the following person(s) and/or organization(s):
Person(s) and/or Organization(s)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
I understand that this information is not to be re-released to
any person or facility except as provided by law. This release
will continue until termination of treatment unless otherwise
specified: ______________. I understand that I may revoke this
release of information at any time. I understand, however, that
any release which was made prior to my revocation and which was
made in reliance upon this authorization shall not constitute
a breach of my right to confidentiality. Unless I revoke this
authorization prior to such time, this authorization to release
information shall expire when the desired information is sent.
To the extent that my medical record contains information regarding
alcohol or drug treatment that is protected by Federal Regulation
42 CFR, Part 2, I authorize disclosure of such information.
X________________________________
Signature of Patient (if 18 or older);
Or Parent (if patient under 18);
Or Legal Guardian; or Health Care Agent
X______________________ X__/__/__
Printed Name of Patient and Date
or Authorized Person
X__/__/__
Patient’s Date of Birth__________________________________
Signature of Witness
_______________________ __/__/__
Printed Name of Witness and Date
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