Medical Records Request — Modern Family Medicine

📋 Records Requested From

Practice / Facility Name

Physician Name

Phone

Fax

Address

👤 Patient Information

Patient Full Name

Date of Birth

Phone

Address

📄 Records Requested

Other

Date Range From

Date Range To

🎯 Purpose of Request

Other Purpose

✍️ Patient Authorization

I hereby authorize the release of my medical records as indicated above to Modern Family Medicine. I understand this authorization may be revoked in writing at any time, except where action has already been taken. This authorization expires 90 days from the date signed unless otherwise specified.

Patient Signature (or Legal Representative)

Clear

Date

Printed Name

Relationship (if not patient)

Modern Family Medicine

COMPREHENSIVE PRIMARY CARE

Request for Medical Records

✅ Request Submitted