Please Let the office staff for verify before submissionPlease Let the office staff for verify before
submission
Patient InformationPatient Information
AUTHORIZATION TO RELEASE MY MEDICAL RECORDS
INFORMATION TO RELEASE
DISCLOSURE OF SENSITIVE INFORMATION
DELIVERY METHOD
IDENTITY VERIFICATION
NoteNote
If you need records to be sent to multiple locations/recipients or entities,
please complete a separate form for each request. Thank you very much.If you need records to be sent to multiple locations/recipients
or entities, please complete a separate form for each request. Thank you very much.