Medical Record Release Form

Patient Information

First Name Last Name Middle Initial
Address City State
Phone Number   Zip Code
Social Security Number    

Please release my medical records FROM:    
Provider First Name Provider Last Name  
Provider Address City State
Provider Phone Number   Zip Code
Provider Fax Number    
Please send my medical records to:
  Christian Care House Calls
  PO Box 761
  Aledo, TX 76008
  Phone: 817-372-9200
  Fax: 1-877-515-5209
Please release all records including, but not limited to, progress notes, operative notes, laborstory test results, diagnostic tests and x-rays.
I hereby authorize the release of medical records as provided above.
Patient or Responsible Party - PRINTED NAME

Responsible Party Relationship to Patient