Medical Records Transfer Authorization

Submitting this form will create a "Medical Records Transfer Authorization" that you will sign when you arrive for your or the patient's appointment. If you enter your email address, we will also send you a copy of the release.

Complete this form only if you will be transferring records from another doctor.

Your Name*

First Last

Are you a parent or guardian?*

Are you providing consent for the release of records of a minor or other person?

Yes, I am a parent or guardian
No, I am the patient

Patient Name*

First Last

Your Relationship to Patient*

Patient Date of Birth*

Doctor or Practice*

Enter the name of the doctor or practice that is currently holding the records to be released to CarlinVision

Consent: I understand this authorization includes release of all medical records including HIV, Psychiatric Mental Illness, Drug/Alcohol Abuse, Venereal Disease and any other statutory protected diseases. This authorization and consent will expire ninety (90) days following the date signed. I understand that I may revoke this authorization and consent at any time except to the extent that action has previously taken in reliance hereof.

Email

If you would like a copy of your submission sent to you by email, enter your address here.

Enter Email Confirm Email