Wrightstown Family Medicine

Available Forms

Authorization to Release Medical Records Medical History Form New Patient Demographics Patient Portal

Authorization to Release Medical Records

Wrightstown Family Medicine, P.C.

Paul M Caracappa, DO, Ellen H Kim, MD

Margi Johnson, DO, Stephen Stonehouse, MD

AUTHORIZATION TO RELEASE MEDICAL RECORDS:

PATIENT INFORMATION:

Name

DOB

INFORMATION TO BE RELEASED FROM:

Name of Facility or Provider

Phone Number

Fax Number

INFORMATION TO BE SENT TO:

Wrightstown Family Medicine Phone 215-598-1200 Fax 215-598-1201

**ANYTHING OVER 20 PAGES, PLEASE MAIL TO THE ADDRESS BELOW**

INFORMATION TO BE RELEASED: (check one)

The most recent 2 years of pertinent information (chart notes, labs, x-rays, and special tests)

All Medical Records

Specific Information

Please Specifiy

PATIENT AUTHORIZATION:

I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.

*EXCLUDE the following information from the records released (please initial)

Drug/Alcohol abuse/treatment and diagnosis

HIV/AIDS diagnosis, treatment, testing

Sexually transmitted disease

Mental illness or psychiatric diagnosis/treatment

Signature:

(Patient, or Guardian*, or Authorized Representative*)

Date:

2189 Second Street Pike, Wrightstown, PA 18940

P: (215) 598-1200 F: (215) 598-1201

* Required field