Release of Medical Records Form - 9th Street Internal Medicine 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's full name, street address, city, state, and zip code in the designated fields.
3. Fill in the birth date and social security number to ensure accurate identification.
4. Select the specific medical records you wish to release by checking the appropriate boxes for history & physical, laboratory reports, progress notes, radiology reports, diagnostic tests, immunization records, and any other relevant information.
5. Indicate whether you authorize the release of sensitive information related to AIDS/HIV or psychiatric care by initialing in the corresponding section.
6. Provide the name and address of the facility or person receiving this information.
7. Select the purpose of disclosure from options such as referral to specialist or change of doctor.
8. Sign and date the form at the bottom to validate your authorization.

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