Medical Release Form

Name
First Last
Your Birthday
Date Format: MM slash DD slash YYYY
Email
I authorize the release of my information
- To Zion Pain Management
- From Zion Pain Management
In addition to the general authorization to release records to the persons or entities listed above, I authorize the release of the records described as the following:
Release my information to/from
- IHC
- Physician
- Patient
- Attorney/Court Case
- Other Authorization
Physician Name
Physician Address
Physician Fax
Communicable disease related information
- Yes
- No
including records of testing, diagnosis, or treatment of HIV, HIV related illness, AIDS, AIDS related diseases
Drug and alcohol treatment
- Yes
- No
Psychological or Psychiatric information
- Yes
- No
Pathology
- Yes
- No
slides, xrays, videotapes, photographs
Genetic screening
- Yes
- No
Information to be released
- Entire Medical Record
- Records of Visits
- Statement of Charges/Payments
- X-Ray, MRI, CT report(s)
- Other
(Please check all that apply)
Records of Visits
Other Information
Confidential notice:The document accompanying this release contain confidential information belonging to the sender. This information is legally privileged and intended for the use of the individual named above, if you are not the intended recipient, please notify the sender and dispose of the information received. Use of this protected information by anyone other than the recipient is strictly prohibited. This request will expire 90 days from signature date.
Print Your Signature Below*
Date
Date Format: MM slash DD slash YYYY

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