Authorization to Release Medical Records – Advanced Discovery Research

Medical Information Release Authorization Form

By signing this form, I authorize the Medical Provider listed below to release my medical records to:

Advanced Discovery Research
652 Bellemeade Ave NW
Atlanta, GA 30318
Phone: 470-777-8839
Fax: 470-298-3830

Full Name

Phone/Mobile

Date of Birth

Reason for Release of Medical Information

Name of Medical Provider

Provider’s Phone Number

Dates of Treatment

All dates

Select dates

Treatment Start Date

Treatment End Date

Do you have another Provider?

Yes

Signature

Sign Here