Request for Release of Records 02-Request for Release of Records-[239][490] Patient Info First * Last Name * Date of Birth * Social Security Number * Please do not add any dashes or spaces. Medical Record Number * Doctor, Clinic, Hospital Type * DoctorClinicHospitalOther Type Name * Phone * plus1 Add minus1 Remove Effectively immediately, I hereby authorize and request you to release by facsimile or e-mail to: Iman Bar MD 1303 Avocado Suite 100 Newport Beach CA 92660 Ph. 949-706-1212 Fx. 949-229-6466 imanbarmd@gmail.com All medical records concerning any aspect of my medical care. Required * Accepted The beginning of my illness or my first visit with you or your group: Required * Accepted PLEASE SIGN AND DATE THIS DOCUMENT SHOWING THAT YOU HAVE READ AND UNDERSTAND OUR POLICIES. The medical records requested are only to be used for medical care. They will not be released to another party without specific written authorization. A photocopy or facsimile of this request shall be as valid as the original and remain in effect for 12 months from the date of signature below. I may revoke this authorization in writing effective at any time. Thank you for your cooperation and rapid response. Full Name * Today's Date * Patient Signature * signature keyboard Clear Witness Signature * signature keyboard Clear PROHIBITION OF RE-DISCLOSURE and CONFIDENTIALITY NOTE This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulations prohibit you making any further disclosure without the specific written consent of the persons to whom it pertains or as otherwise permitted by such regulations. A general authorization for the release of medical information is NOT sufficient for this purpose. The information released is intended only for the use of the individual(s) or entity(s) listed above and is confidential and legally privileged. Jul 2022 Submit If you are human, leave this field blank.