The Cleveland Clinic Medical Release Form

Medical Release Form
Please complete all fields on the authorization form. If you do not know your CCF number, please leave it blank. You may fax the form once signed and dated to the fax number at the top, or you may mail it to the address indicated. Our normal processing time is 7-10 business days, depending on the availability of the medical record.

• Authorization for the Release of Medical Information to Request Records from the Cleveland Clinic
  
• Authorization for the Release of Psychotherapy Notes
• Authorization for the Release of Medical Information From Other Health Care Facilities

Radiology Images Release Form
Please complete the authorization form. If you do not know your Cleveland Clinic medical record number, please leave it blank. Once the form is signed please fax or mail release to the fax number or address provided at the top of the form. Our normal processing time is 1-2 business days upon receipt of the release and availability of the images.

• Authorization for Release of Radiological Images

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