Medical Release form - Thrive Comprehensive Medical Group

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

Radio Field

X ___ 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:

Request expiration date

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