Fakhoury Medical & Chiropractic Center

  • Ocala, Fl
  • Car Accident or Pain?
  • Call Us First!
Phone-volume Envelope

Medical

Release

form

OCALA FL

medical release form

unique model of multidisciplinary practices under one roof

Auto Accident
Intake Form

Ocala's Top Chiropractor Office

Medical Records Release Form

By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information to the physician/person/facility/entity listed above.

The information you may release subject to this signed release form is as follows:(Required)

Release these records from:

Name
Address

Patient Information

Patient Name
MM slash DD slash YYYY
MM slash DD slash YYYY

OCALA-BASED MEDICAL / CHIROPRACTIC OFFICE

Accessibility by WAH