Elite Sports Medicine
MEDICAL RECORDS REQUEST FORM
Patient Information:
First Name:
Last Name:
Date of Birth:
Phone Number:
Email Address:
Alt Phone:
Address:
City/State/Zip:
Release Records From (Provider or Facility):
Send Records To: Elite Sports Medicine
Attn: Dr. Marc Matarazzo
Phone: (561) 202-8886   Fax: (561) 202-8886
Address: 11380 Prosperity Farms Rd, Suite 204
City: Palm Beach Gardens State: FL ZIP Code: 33410
Information to be Released
I hereby authorize the release of my medical records as specified above to Elite Sports Medicine. This authorization is valid for one year from the date of signature unless revoked in writing. I understand that once information is disclosed pursuant to this authorization, it may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations.
Patient Signature *
Date *
Printed Name *
If signed by someone other than the patient, indicate relationship:
Witness Signature
Date

Thank You!

Your medical records request has been submitted successfully.