Authorization Release Form - The Heard Institute


Please fill in the form to ask questions or submit feedback.		x Indicates a REQUIRED field. Note: The form will not be sent until the required fields are completed.

	Patient Name: x
	DOB: x
	SSN:
	Previous Name: x
	I request and authorize Dr. Michael J. Heard, M.D. and/or his affiliates
	to release the medical records of the patient named above to (provide complete address and phone):
	to obtain the medical records of the patient named above from (provide complete address and phone):
	Health care information relating to the following treatment, condition or dates of treatment:
	Authorization to FAX:
	Telephone
	Fax
	Relationship or status if signed by anyone other than the patient (parent, legal guardian, personal representative, etc.)