REQUEST FOR RELEASE OF MEDICAL RECORDS
1. Patient Information
- 1.1 Patient Name: Alice Rouge
1.2 Incident Date: 01/01/2024
2. Requesting Parties Information
- 2.1 Name of Requestor: Alice Rouge
2.2 Phone: 888-2422
2.3 Email Address: [email protected]
3. Relationship to Patient
- [X] Patient
[-] Parent of Minor
[-] Parent/Legal Guardian of Disabled Adult
[-] Power of Attorney
[-] Beneficiary
[-] Legal Guardian
[-] Executor of Estate
[-] Patient Authorized Representative
[-] Representing Attorney
[-] Law Enforcement
[-] Spouse/Significant Other
4. Declaration & Acknowledgement
By submitting this form, I hereby request that the RCFD release the patient’s health information maintained by RCFD.
Re-Disclosure: I understand that the information used or disclosed may be subject to re-disclosure by the
person, agent, class of persons or facilities receiving it, and may no longer be protected by state and federal
confidentiality laws.
- Signature: arouge
Date: 01/02/2024
I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.