• 480-595-0431

Medical Records Release Form

CAREFREE INTERNAL MEDICINE, PC

Seema Mohan, M.D. & Diana Hrdina, M.D.

PO BOX 5848
CAREFREE, AZ 85377
P: (480) 595-0431 F: (480) 595-2322
www.carefreeinternalmedicine.com

Medical Release Form

I hereby authorize

to release all information included in my medical records to Carefree Internal Medicine. This includes all notes, labs, imaging, tests, and notes from other specialists. This also includes communicable and Sexually Transmitted Disease (STD) results (HIV, Syphilis, Hepatitis, Chlamydia, and Gonorrhea).

Patient's Name

Patient's Social Security Number

Patient's Date of Birth

Address

City:

State:

Zip:

Date of Request

Signature of Patient

Witness

** Please send this Information ASAP for better medical care of our patients **