Cornerstone Primary Healthcare

Available Forms

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Release of Information

Your provider is attempting to request records from a previous provider or specialist. We do not have a valid Release Form on file for you.

Medical Records Release Authorization

I hereby authorize the following healthcare provider(s) and its physicians, employees and agents to release or disclose to Cornerstone Primary Healthcare all of my medical records including records pertaining to treatment, prognosis and diagnosis, including any specially protected or listed records, such as those relating to psychological or psychiatric impairments, drug abuse, alcoholism, sickle cell anemia, or HIV infection.

Provider / Office To Release Records *

Please provide provider/office name, location and fax number.

I further authorize you to provide to and discuss with Cornerstone Primary Healthcare any confidential information with respect to my medical condition or treatment, either formally or informally.

Release Records to:

Cornerstone Primary Healthcare

FAX: 615-824-1622 Address: 117 Maple Row Blvd, Hendersonville Tn 37075

Purpose of Disclosure: For use in continued medical care

Patient Name *

Patient SSN *

Patient Date of Birth *

Records to Release: *

All Records

All Laboratory Results

Specific Records Being Requested: *

Patient/Guardian's Signature: *

Date: *

Relationship to Patient: *

THIS AUTHORIZATION WILL NOT EXPIRE. A PHOTOSTATIC COPY OF THIS AUTHORIZATION IS TO BE CONSIDERED AS VALID AS THE ORIGINAL

* Required field