Laramie Internal Medicine, pc
Laramie's Comprehensive Internal Medicine service
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Laramie Internal Medicine, pc Laramie's Comprehensive Internal Medicine service
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__________________LARAMIE INTERNAL MEDICINE, PC______________________ 1174 N 22nd St. Laramie, WY 82072, 307-745-3536
AUTHORIZATION TO RELEASE MEDICAL RECORDS I hereby authorize the transfer of all the medical records in your possession (including copies of medical records from other Physicians, Clinics/Hospitals, and Specialists.)
PATIENT:____________________________________________DOB_________________ PATIENT:____________________________________________DOB_________________ PATIENT:____________________________________________DOB_________________ PATIENT:____________________________________________DOB_________________
FROM TO ___________________________________ __________________________________ (Name) (Name) ___________________________________ __________________________________ (Complete address) (Complete address) ___________________________________ __________________________________ (City) (State) (Zip) (City) (State) (Zip) ___________________________________ __________________________________ (Phone number) (Phone number) ___________________________________ __________________________________ (Fax number) (Fax number)
REASON FOR LEAVING___________________________________________________ (optional) I hereby release_____________________________and its staff from any and all legal responsibility Or liability that may arise from the release of this form or these Medical Records. This consent expires no later than 1 year from the date of signature. RESPONSIBLE PARTY’S SIGNATURE:___________________________DATE__________ Address:_________________________City:__________________State:_______Zip__________ Phone Number:_____________________________ |
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