Medical Records Request - David S. Weingarden, M.D. & Associates, P.C.

Use this form to authorize the release of your medical records from David S. Weingarden MD & Associates, P.C. to another healthcare provider.

Patient Information

Patient Name

Phone Number

Date of Birth

Street Address

City, State, Zip Code

Release Records To

Name and Address of Physician / Facility

Method of Release

Select how you would like your records sent:

Fax

E-Mail to the Provider

Portal Upload

Information to Release

All records

All records between the dates of:

Records pertaining to:

Purpose: To be used in conjunction with Doctor's efforts to diagnose & treat patient's illness.

This agreement may be revoked at any time (except to the extent that action has already been taken to comply with it). Otherwise, it will remain in effect indefinitely until our office receives a written notice requesting that it be revoked. I consent to use the chosen method above to send my medical records.

Authorization

Patient / Guardian Signature*

Sign here

By signing above (drawing or typing your name), you agree that this constitutes a legally binding signature.

Date

Driver's License Number (for ID Verification)

Request for Copy of Medical Records

Records Request Submitted!