Medical Records Release Form
MEDICAL RECORDS RELEASE FORM
By signing this form, I authorize the Maryland Center for Brain Health to release confidential health information about me and discuss ongoing treatments by releasing a copy of my medical records, or a summary of a narrative of my protected health information, to the physician/person/facility/entity listed below.
Client Name*
Required field!
Date of Birth*
Required field!
Email*
Required field!
Phone*
Required field!
POA Name (If applicable)
Required field!
Please release my protected health information to the following physician/person/facility/entity and/or those directly associated in my medical care:*
Please note name and phone number of those entities
Required field!
The purpose of the release of this information is:*
Required field!
Required field!
Date*
Required field!