Print this page, sign and give to your doctor, dentist, therapist, chiropractor and all others who keep your medical files.
Patient Request for Non-Disclosure of Medical Records
In particular, I decline to consent to the release of my medical records for the purpose of entry into a computer database which may be accessed by third parties outside of the offices or hospitals utilized by my physician.
__________________________________________________ Signature __________Date
____________________________City ____________ State ____________________Zip