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Release of Information
This is the form required by our medical records department to verify we have your permission to release medical records. For your convenience, you may print this form and fill it out at home.
Please note that this consent form must be signed by the patient if the patient is 18 years of age or older.
When it is completed, either mail or bring the form to the office where you are usually seen. Faxed forms can not be accepted because an original signature is required.
Please allow seven to ten business days to process this request.
Please click on the link to the form to open it and then click on the picture of the printer which appears just above the opened form to print a copy to fill out.
Release of Information Form
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