Medical Record Release
UPLOAD PICTURES (SECURE) (image types: jpg, gif, png, jpeg)
Upload picture of Front of Government issued ID:
Upload picture of Back of Government issued ID:
PRINT OR SAVE
If you are satisfied with the information you provided, you may press the "DOWNLOAD FOR PRINTING OR SAVING" button to save or print these forms.
SEND EMAIL TO US
To send us the completed forms now, press the "SECURELY SEND FORMS TO OUR OFFICE" button.
*** After pressing the "SECURELY SEND FORMS TO OUR OFFICE" button, your information will be erased from the server.
Our System uses a HIPAA compliant secure email server to protect your information.
