Medical Records Release Form By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or a narrative of my protected health information, to the physician/person/facility/entity listed below. Patient Name * Date of Birth * The information you may release subject to this signed release form is as follows: Complete Records Lab Reports Operative Reports History & Physical Radiology Reports Hospital Records Progress Notes Pathology Reports Medication Record Care Plan Treatment Record Other (please specify below) Release my protected health information to the following physician/person/facility/entity: Name: Dr. Travis Mendel Radiation Oncologist Address: 7420 Remcon Cir. Bldg. A City: El Paso State: TX Zip Code: 79912 Patient Name * Patient Date of Birth or Social Security Number * Printed name of Patient or Personal Representative * Date *
