Release of Medical Information

Permission to get records

Permission to get sensitive information

By putting my initials by each item below, I understand that I give permission for records to be sent that may contain information about:

I understand that:

    I do not have to give my permission to share these records.
  • If I want to take away the permission for my doctor to get these records,
  • I need to talk to my doctor or a staff person and sign a paper.
  • This form is only good for 3 months from the date I sign it.

Requesting records from:

Types of records we are requesting

Records within the following dates:

Please send records to:

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