Medical Records Release Form

Medical Records Release Form
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Authorization for Parker County Imaging Center LLC to release medical records to:
Send Records To:
This authorization serves as written consent for Parker County Imaging Center LLC to release and transmit to the above-named individual or entity a complete copy of any and all medical records maintained by Parker County Imaging Center LLC. This includes, but is not limited to, imaging reports, diagnostic results, clinical notes, and any other medical documentation contained within the patient’s records. The undersigned hereby authorizes the disclosure of this information for the purpose of obtaining personal health information or for any other legally permitted purpose as requested.

This authorization shall remain in effect from the date of its execution until specifically revoked by me.
Patient Signature

Clear
If patient is a minor, parent or guardian signature.
Date

MonthDayYear
Date
Should be Empty: