Medical release form - Chesapeake Public Schools 2025

1. Click ‘Get Form’ to open the Medical release form in the editor.
2. Begin by entering the date at the top of the form. This helps establish when the request is made.
3. In the section labeled 'Name of Prior Facility', input the name of the medical facility where previous mammogram films were taken.
4. Next, provide the complete address of that facility, including city, state, and zip code.
5. Fill in the phone number and fax number for the prior facility to ensure easy communication.
6. Enter the patient's name and Social Security number (SS#) in their respective fields for identification purposes.
7. Include the patient's date of birth to further verify identity.
8. Finally, ensure that you sign and date at the bottom of the form to authorize this request.

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