St Lawrence Health Alliance, Inc.
3 Lyon Place, Ogdensburg, NY 13669
Phone: 315-394-7542 Fax: 315-394-8995

MEDICAL RECORDS RELEASE FORM

To:________________________________ Date:_______________________
Name of Doctor or Institution Expiration:__________________
___________________________________
Address
___________________________________

I hereby authorize the release of my general medical records. Nature of information to be released:

Check which apply:

_______ Most recent immunizations, labs, progress notes or all.

_______ Furthermore, I authorize the release of my medical records pertaining to psychiatric, drug and/or alcohol abuse issues.

Released to:

_______________________________________
Doctor or Institution name

_______________________________________
Address

_______________________________________

__________________________________ X__________________________________
Patient’s Name Printed Patient or Legal Representative’s Signature
__________________________________
Patient’s Address
__________________________________ 		X __________________________________
Witness’ Signature
__________________________________ Date:_______________________________
Patient’s Date of Birth