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Patient Information


"Patient" is the individual who is seeking to have Medical Records released.
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Current Location of Medical Records


The Medical Records for the Patient are currently held by the following organizations. This is where the Medical Records Release will be sent. Organizations includes doctors’ offices and clinics, hospitals, health clinics (which include chiropractors, physiotherapists, massage therapists), HMOs, Medicare and Medicaide.

Organization Details

Sharing Medical Records


The Patient’s Medical Records may be shared with other healthcare providers, and with individuals/organizations that the Patient and/or Legal Representative specify below. Common examples of non-health providers that may require Medical Records include insurance companies, lawyers, employers and exercise facilities.

Corrections Required to Existing Medical Records


If there are identified errors within the Patient’s existing Medical Records, you may ask for them to be corrected using this Release.

Duration of Medical Release

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To prevent the unauthorized disclosure of your Medical Records in the future it highly recommended that you limit the duration of your Medical Records Release to less than two years.

Signing Details


Location where Release will be signed: