Name:

Address:

City, State and Zip

Phone#

Fax #

SSN#

Insurance carrier and number #

I, _(full name)_________________________________, wish to have my medical records released to myself. Please mail them to /// fax them to (circle one) the address above.

Thanks for your cooperation, it is appreciated.

Signed : _____________________________________________________

                             Name      (_____________________________________)

Witnessed: ______________________________________

Date: __/__/____

(witnessing is not usually necessary but might speed things up in some cases.)