Release of Medical Information:
Download the Release of Medical Information form here.
Please fill out all highlighted sections, including:
- Patient’s Name, Date of Birth, Address and Phone Number
- Facility Authorized to Release Information to:
- Records Released to you - write in “SELF"
- Records Released to another Provider or Facility - please fill in the Providers name, address, phone and FAX number.
- Health Information to be disclosed - include all dates of
service, what type of records you want released (labs, x-ray, complete,
etc.), why you need the information (treatment, insurance, personal),
- The Yes/No question is an authorization to release any sensitive
information. Typically this should be marked yes if you require all of
your information to be released.
- Patient’s or Authorized Personal Representative’s Signature – please sign, date and time.
- Leave the Witness Signature line and everything below it blank.
Please return to us via fax at 858-244-3524. If you have any questions, please call 618-241-8547.
* Please call an hour in advance if requesting radiology images on CD to allow time for processing.