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I request that a copy of the following information contained in my medical record to be: Forwarded to
Obtained from  

 

Please check records to be released or obtained Immunization Records
Lab Results
X-ray/Imaging Results
Nurses/MD Notes

I wish to exclude the release of theses items and confirmation pertaining to:

An unaltered photocopy of this document may be accepeted in lieu of the original and I understand that the original will be maintained in my records. This authorization will remain in effect until this request is processed.
This authorization will remain in effect until:  
 

By clicking this box, I consent to the release of my medical information.
 
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