Medical Record Request

AUTHORIZATION FOR THE RELEASE OF PATIENT MEDICAL RECORDS FROM DR. RUBINFELD'S OFFICES TO ANOTHER HEALTHCARE PROVIDER.

This Authorization form is designed to meet the requirements of federal privacy regulations issued by the Department of Health and Human Services at 42 CFR § 164.508 and the Annotated Code of Maryland, Title 10 Health General Article §§ 4-301-4-307.


I hereby authorize Dr. Roy Rubinfeld to release my protected health information. *
Patient Full Name *
Patient Full Name
Doctor's Phone Number: *
Doctor's Phone Number:
Doctor's Fax:
Doctor's Fax: