Medical Records Release Authorization

In order to avoid a delay, this form must be completed in its entirety.

Patient Name *
Madien Name
D.O.B *
SS# *
Home Phone *
Work Phone

Permission is hereby granted to Columbus Orthopaedic Clinic to release medical information to the individual/organization as noted below:
for the purpose of: *

Mail to:
Name *
Address *
City *
State *
Zip *
Fax to another medical entity
call when ready for pickup
person picking up records

Please check information to be released:
All records, excluding records from other physicians
Office Notes only
Surgical Records
Xray/MRI films
Therapy reports
Xray/MRI reports
Diagnostic test results
Patient information
Other
other info

This authorization will be valid for two years after the date of the patient's signature as it appears below, or by whichever comes sooner.

I understand I have the right to refuse this authorization, in writing, and Columbus Orthopaedic Clinic is released from all legal liability that may arise from the released information requested.
I agree *
Date *