Request Medical Records

If you would like information from your medical record sent to you or transferred to or from another clinic, you will need to complete and submit the below form. Please be sure to provide all information requested on the form in order for your request to be processed without delay. Please allow 15 business days for processing. If records are needed by a particular date, please specify this in the appropriate place on the form. You may fax, mail or bring this form to our clinic or the clinic or facility you are requesting records from.

Records Release Form


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