Authorization For Release of MEDICAL RECORDS

- Step 1 of 2

Name of Patient *

First

Middle

Last

Patient Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth: *

Who are medical records being sent to? *

Myself
Medical Facility / Law Office / HR Manager

How would you like to receive your medical recrods?

Email
Fax
Mail
Print

Email Address *

CONFIDENTIALITY NOTICE: Email communication, including all attachments and related content, may contain private, confidential, or legally privileged information intended for the sole use of the designated and/or duly authorized recipient(s). Please note by signing below you acknowledge, you will receive your medical records in an unencrypted e-mail at your request.

I consent to receive my medical records in an unencrypted email at my request. Please Initial Below: *

I consent to a charge of $.20/page. Please Initial Below: *

You can pick up your Medical Records at the front office of Progressive Physical Therapy. Office Hours: M-F 8am-4.30pm

I consent to a charge of $.20/page. Please Initial Below: *

Mail to Address Provided Above *

Yes
No, a different address

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Fax Number *

Name of Facility:

Facility Address:

Address Line 1

Address Line 2

City

State

Zip Code

Facility Phone:

Facility Fax:

Facility Email:

CONFIDENTIALITY NOTICE: Email communication, including all attachments and related content, may contain private, confidential, or legally privileged information intended for the sole use of the designated and/or duly authorized recipient(s). Please note by signing below you acknowledge, your medical records will be sent in an unencrypted e-mail at your request.

Please describe the records you are requesting. If applicable, include a date range and diagnosis. Please specify if you are also requesting billing records.

Electronic Signature *

I understand an electronic signature constitutes a legal signature confirming I authorize the release of my medical records. Please send records to the address, email, or fax number above. A digital copy of the record release may serve as the original release.

Today's Date *

Comment

Hours of Operation

Monday - Friday

8:00am - 4:30pm

Office Location

Progressive
Physical Therapy

155 W. Duval Rd.
Green Valley, AZ 85614
Phone: (520) 648-3132
FAX: (520) 648-1861

Get Directions ⟶

Hours of Operation

Monday - Friday

8:00am - 4:30pm

Office Location

Progressive
Physical Therapy

Are you ready to start feeling better?

Patient Resources

Quick Links

Authorization For Release of MEDICAL RECORDS

Hours of Operation

Monday - Friday

8:00am - 4:30pm

Office Location

ProgressivePhysical Therapy

Are you ready to start feeling better?

Call Today: (520) 648-3132

Patient Resources

Quick Links

Progressive
Physical Therapy