HomeMy WebLinkAbout52A - Form 3
Town of Lexington
Police Department
Chief Mark J. Corr
1575 MASSACHUSETTS AVENUE • LEXINGTON, MASSACHUSETTS 02420
781-862-1212/781-863-1291
IA Form - 3 (2016)
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
PATIENT: _____________________________________________________________________________
(LAST NAME) (FIRST NAME) (M.I.)
ADDRESS: ____________________________________________________________________________
____________________________________________________________________________
DATE OF BIRTH: _______________________________ PHONE: ________________________________
RELEASE:
I HEREBY AUTHORIZE __________________________________________________________ TO RELEASE TO THE LEXINGTON CHIEF OF
POLICE, OR HIS DESIGNEE, ALL RECORDS OF MEDICAL TREATMENT PERTAINING TO ANY SICKNESS OR INJURY FOR WHICH I
RECEIVED TREATMENT. THE RELEASE OF MY MEDICAL RECORDS IS SUBJECT TO THE FOLLOWING LIMITATIONS (PLEASE INITIAL
ONLY THOSE SECTIONS WHICH WILL APPLY):
1._______ Confine release of records to treatment or admissions on the following date or dates: _______________________________________
2. _______ No limitations placed on dates, history or illness, or diagnostic and therapeutic information, including any treatments for psychiatric,
drug, or alcohol abuse.
3._______ Other: _____________________________________________________________________________________________________
SIGNATURES:
SIGNATURE OF PATIENT: _________________________________________ DATE: ___________________
IF PATIENT IS JUVENILE OR UNABLE TO SIGN
NAME OF PARENT/GUARDIAN/OTHER: _______________________________________________________
RELATIONSHIP TO PATIENT: _______________________________________________________________
ADDRESS: _______________________________________________________________________________
WITNESS:
NAME OF WITNESS (print): _________________________________________________________________
ADDRESS: _______________________________________________________________________________
SIGNATURE: _________________________________________ DATE: ______________________________
MEDICAL FACILITY INFORMATION:
NAME OF MEDICAL FACILITY: ______________________________________________________________
NAME OF PERSON RELEASING INFORMATION: _______________________________________________