To Obtain Your Other Records

MEDICAL RECORDS RELEASE

 

Date:  __________________

 

To: ____________________________________________________________
                                                            Doctor or Hospital

            Address: ______________________________________________

            City, State, Zip: ________________________________________

 

I hereby authorize and request you to release to Kevin D. Nolan, M.D. and/or William F. Oppat, M.D. and/or Tamer N. Boules, M.D. at the above address, my complete medical record in your possession concerning my illness and / or treatment during the period from ________________________ to ____________________________.

 

Signed: __________________________________________
                        Patient’s signature

Witness: _________________________________________

Relationship: _____________________________________