Med. Release Auth.


To: (Name of physician or facility):

Address:

Phone: Fax:

I hereby authorize and request you to release the following medical records in your possession to:

Howard J. Lang, D.O., F.A.A.E.M.

Derek H. Lang, D.O.

Family Medicine, Allergy & Environmental Medicine

789 Lonesome Dove Trail

Hurst, TX 76054

Ph: (817) 577-0480 Fax: (817) 581-0167

(Please Mark One) Date

  • All records
    • from to
  • Laboratory Studies
    • from to
  • Office Notes
    • from to
  • Other (please specify)
    • from to

from to

Patients Name:

Address:

Patients DOB:

Date:

Leave this empty:

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Signature Certificate
Document name: Med. Release Auth.
lock iconUnique Document ID: e3dacc26e19db93732b2e425e5607b7982354428
Timestamp Audit
May 25, 2021 10:35 pm CSTMed. Release Auth. Uploaded by Derek Lang - langnewpatient@gmail.com IP 174.108.1.127