Release of Patient Information Form

Instructions

Your medical records are important to you. We want to make it as simple as possible to receive your records. Due to changes in federal law, a revised release of information disclosure form must be used for all requests for personal health information.

Please print this form, fill it out completely and take it to your physician’s office or the facility from which you wish to obtain your medical records. Be sure to sign and date the form. Incomplete forms will be returned to you unprocessed. A separate authorization must be completed for each request.

A fee may be charged.