Central Hub

Medical Records Release

Complete your authorization and send it to our medical records team.

Authorization to release healthcare information

Tell us where to send your records, choose what to release, and sign below.

Download fillable PDF

Online submission is currently unavailable.

You can download the fillable PDF and call 301-284-3181 for return instructions.

Fields marked * are required. Completed authorizations are sent to MedicalRecords@drsfirst.com.

1. Patient information

Patient full name *Date of birth *

2. Where should we send your records?

I request and authorize FIRST MEDICAL ASSOCIATES to release my healthcare information to the person/practice listed above.

Practice / physician's name *

Practice phone (optional)Practice fax (optional)

Practice street address *

City *

State *ZIP code *

3. Information to release

This request and authorization applies to the following. Select at least one option. *

All healthcare informationHealthcare information relating to a specific treatment, condition or datesOther healthcare information

Additional permissions (optional)

These permissions are separate choices. Check only those you authorize.

I authorize the release of my STD, HIV/AIDS results, whether they are negative or positive, to the person/practice listed above.I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person/practice listed above.

STD definition from the original form

Definition: Sexually Transmitted Diseases (STD) as defined by law, RCW 70.24 et seq, including herpes, herpes simplex, human papillomavirus, wart, genital wart, condyloma, Chlamydia, nonspecific urethritis, syphilis, VDRL, lymphogranuloma venereum, HIV, AIDS & gonorrhea.

4. Sign your authorization

If younger than 18, parent/guardian must sign. This authorization expires one year after it is signed and may be revoked by patient at any time.

Electronic signature (full name) *I am signing as *

The signature date is recorded automatically when you submit.

By checking this box and typing my full name, I intend to electronically sign this authorization. I confirm that I am the patient or the patient's parent/legal guardian and authorize First Medical Associates to process this request. *

Please review your entries before submitting. Our records team reviews the authorization before releasing records. Privacy Policy