Patient Name ____________________________________________________________
Birthdate ______________________ Soc. Sec. Number __________________________
I hereby authorize release of the requested records of the above named patient from:
(Name and address of doctor/facility that the records are being requested from: )
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
including progress notes, laboratory reports, X-ray reports (no films), procedure notes, discharge
summaries, history and physical exams, misc. records __________________________
________________________________________________________________________
(to include all confidential HIV related information if initialed here _____), alcohol and drug abuse
related information and confidential mental health diagnosis and treatment information unless
specified otherwise here in writing: ___________________________________________
Please send records to:
Dr. Dana Myatt
P.O. Box 900
Snowflake, AZ 85937
FAX: (928) 536-5691
For the purposes of ___ continuing care ___ consultation ___other: _______________
Including dates from _________________________to _____________________
This consent will expire 60 days after the date signed below. I have given my consent freely,
voluntarily and without coercion.
___________________________________________ _____________________
Signature of Patient or Guardian (if under 18) and Date
___________________________________________ _____________________
Witness Signature and Date
