Medical Records Request Form Medical Records Request Form I hereby authorize the Medical Group / Physician named below to release my medical record/protected health information to Laredo Arthritis & Rheumatology Center. PLLC:Medical Group(s) / Physician(s): Patient Name: Age DOB MM slash DD slash YYYY Social SecurityHome PhoneMobile PhoneWork PhonePlease Release the following: Entire Record Clinical Notes Third Choice Labs X-Rays Diagnostic Tests Other: Biopsies, MRl's, EMGs, CT Scans, PFT'S, echocardiogram reports SignatureI give permission for the release of any information in my records including information relevant to substance abuse, psychiatric/mental health services, and/or HIV information. I grant this authorization for a period of one hundred eighty (180) days. I may revoke this authorization at any time in writing although I cannot undo its prior use.Date MM slash DD slash YYYY