Medical records

Medical Release Form

Use this form to request the release of medical information to Thrive Comprehensive Medical Group for review and evaluation.

Medical Record Release Request

PATIENT REQUEST FOR RELEASE OF MEDICAL INFORMATION:

THRIVE COMPREHENSIVE MEDICAL GROUP

18607 Ventura Blvd, Suite 102 Tarzana CA 91356

Phone: 8186001472

Fax back to: 8186001494

Patient First Name

Patient Last Name

Patient Date of birth

Patient Phone/Mobile/Home

Patient Email

Facility releasing patient information

Enter information pertaining to the facility that currently has your medical information.

Name of the facility

Doctor’s Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Facility FAX number

Facility phone number

I authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection with a legal claim. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:

Latest Visit notes

Clinical Notes

Radiology results

Lab results

Referral notes

ALL DOCUMENTS

Request expiration date

Your Message

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