Medical Record Release Download PDF Medical Record Release Medical Record Release The following patient has asked us to request that his/her medical records be released and forwarded to our office. In order for us to fully evaluate this patient’s health and make informed decisions, the patient has approved our request for copies of all relevant medical records in your database. Please be sure to include any lab results, ultrasounds, CTs/MRIs, x-rays, pathology, or biopsy reports for continuation of care. Signature signature keyboard Clear Date Patient Name Patient Name First Name First Name Last Name Last Name Middle name Middle Age SS# DOB Address Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Submit If you are human, leave this field blank.