The Family Doctor's Office, P.C.
Steven A. Carder, M.D.
Westowne 3, Suite 303
Liberty, MO 64068
Phone: 816-415-2999 Fax: 816-415-9989
To _______________________________________
_______________________________________
_______________________________________
_______________________________________
Release of medical records for _____________________________________ (Name)
Date of Birth __________________
Choose one by circling it:
- Send records to our address above, preferably by Fax.
- Receive records from our office. We will send them by Fax if possible.
Below, circle any portions of your record that your do not want released:
- Mental Health
- Addiction
- HIV
- Workman’s Compensation
- Other _______________________
The last two years of records are requested unless something else is specified here ____________
Signature of patient/guardian _______________________________
Relationship to patient ___________________________
Date signed ___________________________
This release is good for one year after the date signed unless another time is specified.
A photocopy or facsimile of this authorization is equivalent to the original.
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