Spring Hill Primary Care
Patient Name *
Date of Birth *
Phone (Home) *
Phone (Work)
Address *
City / State / Zip *
Facility Name *
Facility Phone *
Facility Fax
Facility Address *
If Other, please specify
If Other Dates, specify
Specific Information Requested
Recipient Name *
Recipient Address *
Delivery Method * FaxEmailMailPick Up
Fax Number
Phone Number
Expiration Date *
Signature (Type Full Name) *
Date Signed *
Printed Name of Authorized Representative *
Relationship to Patient *
Address & Phone of Authorized Representative *
I have read and understand the Authorization for Release of Medical Information.