Elevated Health NYC - Medical Records Release Form

Elevated Health NYC

Patient First Name

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Patient Last Name

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Date of Birth:

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Address

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Phone:

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Records Requested from:

Name (Doctor’s Office):

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Doctor’s Office Fax #:

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Date(s) of Service:

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Records Needed:

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Fax Records To:

Attn:

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This will fax To: 917-997-9457

I, _________________________(patient name below), hereby grant permission for you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the physician/person/facility/entity.

Printed Name:

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Date:

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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