Online Forms

I understand that the originals of all records generated while I was a patient of this practice will be kept and, upon request, I will be provided a copy of them. I also understand to ensure confidentiality that I may be asked to show identification including picture, such as a driver's license. I realize this is for my protection and to help ensure my confidentiality. Further, I understand that I may be asked to pay a reasonable charge for copying my records and that this amount must be paid before the records will be released.

The reason I am requesting these records is:

I have carefully read this form, and I wish to have the designated medical information released. I will not hold the above name responsible for any misuse of this information which may occur. I further understand that this release remains in effect for all subsequent disclosures as above for 30 months unless I present a written, signed, and dated revocation prior to the expiration date. A copy of this disclosure will be provided upon request.