Executive Health Group, PC

Available Forms

Portal Medical Release Form for EHG Nurse

Executive Health Group

Release of Medical Records

I, the undersigned patient, request a copy of my Medical Records:

Name:

Address:

Date of Birth:

Social Security Number:

Information to be disclosed:

I authorize the release of the following health information: (check the applicable box below)

Information to be disclosed:

1)All of my health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received by me

2)Only the following records or types of health information:

Please Specify if Option 2 is selected above.

Please release the requested information to: Executive Health Group J. Rand Baggesen, M.D. Amy McConnell, M.D. Phone: 804-560-3295 Fax: 888-526-2112 Please process this request within 15 calendar days, as provided by law. A copy of this authorization shall be deemed as valid as an original I hereby authorize to finish the medical information requested to Executive Health Group, including the results of laboratory tests for infectious disease, if applicable.

Patient Signature *

Please type you name for signature.

Date: *

* Required field