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<br />Town of Lexington <br />Police Department <br />Chief Mark J. Corr <br /> <br /> <br /> <br />1575 MASSACHUSETTS AVENUE • LEXINGTON, MASSACHUSETTS 02420 <br />781-862-1212/781-863-1291 <br />IA Form - 3 (2016) <br />AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS <br /> <br />PATIENT: _____________________________________________________________________________ <br /> (LAST NAME) (FIRST NAME) (M.I.) <br /> <br />ADDRESS: ____________________________________________________________________________ <br /> <br /> ____________________________________________________________________________ <br /> <br />DATE OF BIRTH: _______________________________ PHONE: ________________________________ <br /> RELEASE: <br /> <br />I HEREBY AUTHORIZE __________________________________________________________ TO RELEASE TO THE LEXINGTON CHIEF OF <br />POLICE, OR HIS DESIGNEE, ALL RECORDS OF MEDICAL TREATMENT PERTAINING TO ANY SICKNESS OR INJURY FOR WHICH I <br />RECEIVED TREATMENT. THE RELEASE OF MY MEDICAL RECORDS IS SUBJECT TO THE FOLLOWING LIMITATIONS (PLEASE INITIAL <br />ONLY THOSE SECTIONS WHICH WILL APPLY): <br /> <br />1._______ Confine release of records to treatment or admissions on the following date or dates: _______________________________________ <br /> <br />2. _______ No limitations placed on dates, history or illness, or diagnostic and therapeutic information, including any treatments for psychiatric, <br />drug, or alcohol abuse. <br />3._______ Other: _____________________________________________________________________________________________________ <br /> <br />SIGNATURES: <br /> <br />SIGNATURE OF PATIENT: _________________________________________ DATE: ___________________ <br /> <br />IF PATIENT IS JUVENILE OR UNABLE TO SIGN <br /> <br />NAME OF PARENT/GUARDIAN/OTHER: _______________________________________________________ <br /> <br />RELATIONSHIP TO PATIENT: _______________________________________________________________ <br /> <br />ADDRESS: _______________________________________________________________________________ <br /> WITNESS: <br /> <br />NAME OF WITNESS (print): _________________________________________________________________ <br /> <br />ADDRESS: _______________________________________________________________________________ <br /> <br />SIGNATURE: _________________________________________ DATE: ______________________________ <br /> MEDICAL FACILITY INFORMATION: <br /> <br />NAME OF MEDICAL FACILITY: ______________________________________________________________ <br /> <br />NAME OF PERSON RELEASING INFORMATION: _______________________________________________