Records Release Authorization Form

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This form can be used to request previous medical records from OB/Gyn's, primary care physicians, or other healthcare providers.

Attention:

Doctor/Hospital__________________________________

Address:_________________________________________

I hereby authorize and request you to release to:

Reproductive Medicine Associates (Please circle which location):

Morristown 111 Madison Avenue Suite 100 Morristown, NJ 07960 Phone: 973-971-4600 Fax: 973-290-8370

West Orange 769 Northfield Avenue Suite 228 West Orange, NJ 07052 Phone: 973-325-2229 Fax: 973-325-5645

Englewood 25 Rockwood Place First Floor Englewood, NJ 07631 Phone: 201-569-7773 Fax: 201-569-8143

Somerset 100 Franklin Square Dr. Suite 200 Somerset, NJ 08873 Phone: 732-537-0631 Fax: 732-537-0134

The complete history records in your possession, concerning my illness and/or treatment during the period from _________ to____________.

Name_________________________ Date_____________

Address:____________________________________________

Signature:___________________________________________