Medical Records Release Form | Dr. Mahsa Sohrab

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AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Please complete all fields to authorize the disclosure of your medical records.

Patient Full Name:

Date of Birth:

I request and authorize Dr. Mahsa Sohrab to release my healthcare information to:

Recipient Name / Facility:

Mailing Address:

Fax Number:

Attention To:

This request applies ONLY to healthcare information relating to the following specific treatment, condition, or dates of service:

By signing below, I understand and agree to the following terms:

Revocation: I may revoke this authorization at any time by providing written notice to the practice office.
Continuity of Care: The practice will not condition my treatment or payment based on whether I sign this form.
Voluntary Consent: I am signing this authorization freely, voluntarily, and under no pressure to do so.
Re-disclosure: Information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy laws (HIPAA).
Review Opportunity: I acknowledge that I have had the opportunity to review this authorization and fully understand its intent and use.
Expiration: This authorization automatically expires six (6) months from the date signed, unless a different date or event is specified below.

Patient Signature:

Date:

Parent / Guardian Name:

Relationship to Patient:

Guardian Signature:

Date:

THIS IS AN ONLINE FORM. DO NOT PRINT