AUTHORIZATION
FOR RELEASE OF MEDICAL RECORDS TO
ROBERT ROSEN, D.O.
422 Lacey Road, Forked River, NJ
08731 609-971-7701
300 W. Water
Street, Toms River, NJ 08753 732-244-4566
PATIENT’S NAME & ADDRESS
_____________________________________________________________________________________________________
I HEREBY REQUEST THAT MY MEDICAL RECORDS BE
RELEASED FROM
_____________________________________________________________________________________________________
PURPOSE OF RELEASE
__ PERMANENT TRANSFER __ LEGAL __ REIMBURSEMENT __
REFERRAL __ OTHER_________________
_____________________________________________________________________________________________________
INFORMATION TO BE RELEASED
__ CHART NOTES __ LABORATORY RESULTS __ PROCEDURE RECORDS
__ MEDICATION RECORDS OTHER___________________________________________________
_____________________________________________________________________________________________________
AUTHORIZING SIGNATURE
SIGNATURE X_________________________________________________________DATE_________________________
RELATIONSHIP (IF PATIENT IS A
MINOR)_________________________________
_____________________________________________________________________________________________________
I SPECIFICALLY CONSENT TO THE TRANSMISSION OF THESE MEDICAL
RECORDS VIA FAX MACHINE
OR E MAIL _____YES ____ NO
SIGNATURE X
________________________________________________________DATE_________________________
_____________________________________________________________________________________________________
THESE QUESTIONS ARE OPTIONAL
(SOME INFORMATION REQUIRES A SPECIFIC AUTHORIZATION TO BE RELEASED)
I recognize that the information disclosed may contain
DRUG/ALCOHOL/MENTAL HEALTH information that is protected by federal
and state law. I specifically consent to disclosure of such
information.
SIGNATURE X_____________________________________________________DATE_________________________
I recognize that the information disclosed may contain
information regarding HIV/AIDS testing. I specifically
consent to disclosure of such information.
SIGNATURE X_____________________________________________________DATE_________________________
THIS AUTHORIZATION MAY BE REVOKED AT ANY TIME
UNLESS PRIOR ACTION HAS BEEN TAKEN AS A RESULT OF
THIS FORM
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