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Release of Medical Records Form - 9th Street Internal Medicine 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the patient's full name, street address, city, state, and zip code in the designated fields.
- Fill in the birth date and social security number to ensure accurate identification.
- 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.
- Indicate whether you authorize the release of sensitive information related to AIDS/HIV or psychiatric care by initialing in the corresponding section.
- Provide the name and address of the facility or person receiving this information.
- Select the purpose of disclosure from options such as referral to specialist or change of doctor.
- Sign and date the form at the bottom to validate your authorization.
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ninth street internal medicine patient portal
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