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Medical Record Release

Medical Record Release

The following patient has asked us to request that his/her medical records be released and forwarded to our office.

In order for us to fully evaluate this patient’s health and make informed decisions, the patient has approved our request for copies of all relevant medical records in your database. Please be sure to include any lab results, ultrasounds, CTs/MRIs, x-rays, pathology, or biopsy reports for continuation of care.

Patient Name
Patient Name
First Name
Last Name
Middle
Address
Address
City
State
Zip
Release of Information

THE FOLLOWING AUTHORIZATION MUST BE COMPLETED IN ORDER FOR US TO RELEASE ANY PATIENT INFORMATION

Name
Name
First Name
Last Name
Name
Name
First Name
Last Name