Medical Records Request

  • IF YOU DO NOT WANT CERTAIN PORTIONS OF YOUR MEDICAL RECORDS RELEASED, PLEASE READ THE SECTION CAREFULLY AND CHECK THE BOXES FOR INFORMATION YOU DO NOT WANT TO BE RELEASED, OTHERWISE, YOUR RECORDS WILL BE RELEASED AS SPECIFIED ABOVE.
  • Expiration or revocation of authorization: I understand that I may revoke this authorization at any time and that unless an earlier date is specified it will automatically expire 12 months after the date affixed below. Use of copies: a copy of this authorization may be utilized with the same effectiveness as an original.