AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS 

 

 
 
 
Doctor/ Practice Name:___________________________________________________________ 

 

Address:______________________________________________________________________ 

 

Phone:________________________________________________________________________ 

 

Fax:__________________________________________________________________________ 

 

I hereby authorize and request you to release all medical information, including information 
related to psychiatric care, drug and alcohol abuse, and HIV/AIDS to: 

 
 

Dr. Boris Karanfilov / Dr. Sumit Bapna 

5378 Avery Rd. 

Dublin, OH 43016 

Phone: (614) 771-9871 

Fax: (614) 771-9877 

 

 

Patient Name:__________________________________________________________________ 

 

Date of Birth:__________________________________________________________________ 

 

Address:______________________________________________________________________ 

 

Signature:______________________________________________Date:___________________ 

 

Witness:_______________________________________________Date:___________________