CONSENT FOR RELEASE OF MEDICAL RECORDS
AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION TO:
ONCALL HEALTHCARE - MAILING ADDRESS
4939 W RAY ROAD, SUITE 4-302
CHANDLER, AZ 85226
www.oncallhc.com
EMAIL: healthcare@oncallhc.com
FAX: (888) 518-4950
Patients Full Legal Name *
Your answer
Patient Date of Birth *
MM
/
DD
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YYYY
INFORMATION TO BE RELEASED
Initial Medical Exam

Last 6 Months (or most recent) Progress Notes

Discharge Summary (If Any)

Diagnostic Test Results (Labs, Imaging, Other)

REQUESTING RECORDS FROM
Office Name *
Your answer
Address *
Your answer
Telephone Number *
Your answer
Fax Number *
Your answer
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