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Authorization of Release Form

I, hereby authorize

To release my medical records to:

The following information:

Complete Records
Primary Care Physician Notes
Medical Specialist Notes
Immunization Records
Lab Results
X-Ray Results
Cardiovascular tests/studies
Services from thru
Other

Contact Us

Office Hours
Monday:9:00 AM - 5:00 PM
Tuesday:9:00 AM - 5:00 PM
Wednesday:9:00 AM - 5:00 PM
Thursday:9:00 AM - 5:00 PM
Friday:9:00 AM - 5:00 PM
Saturday:Closed
Sunday:Closed


1 to 2 Saturdays per month from 9 AM to 12 PM