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

Date

By clicking this box, I affirm that the information being submitted is accurate and true to the best of my knowledge. I am the patient, or I have the express permission of the patient to submit this personal / health care information.