Request for Release of Medical Records

Today’s Date:

To Whom It May Concern:

I,	/	/	-	-	,
Name	Date of Birth	Social Security Number

allow the medical department of
to share the following information from my medical records:

TB Test Results

Please fax any records that you have indicating the above to 512-482-0071, Attn: Front Steps Shelter Manager, so that I may continue to use their overnight emergency shelter services.

Thank you,

Client Signature