Release of Records

Janet D. Pearl, MD, MSc

Release of Medical Records

Please fill out the form below to allow us access to your relevant medical records to help in our evaluation.
Thank you for your co-operation.

Patient's Legal Name*
First Last
Date of Birth*
Month
Day
Year
Patient's Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Physician or Entity to Release Information*
Phone of Physician or Entity to Release Information*
Fax of Physician or Entity to Release Information*
Person or Entity to Receive Information
- Complete Pain Care - 600 Worcester Rd, Framingham, MA 01702 Ph: 508-665-4344 Fax: 508-665-4355
Specific Information To Be Disclosed
- Office Notes
- Procedure Reports
- Imaging
- Surgery Records
- Other
Purpose
- Medical Consultation / Evaluation
Dates of Service:
This authorization will expire 1 year after date signed.

SIGN BELOW:

When my health information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. The use of disclosure of the information identified above is voluntary and I need not sign this form to ensure health care treatment. I have read and understand the nature of this authorization and understand that it may be revoked upon my written request to the Privacy Officer, except to the extent that action has already been taken on this authorization. Releaser and its agents and employees are hereby authorized to obtain, inspect and reproduce such records and/or information and are hereby relieved of any responsibility of liability that may arise from the release or reproduction of such records and/or information.
Signature of Patient*
Date*
MM slash DD slash YYYY

40653

Janet D. Pearl, MD, MSc

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