Emsellem, MD Medical Director John R 2026

1. Click ‘Get Form’ to open the Emsellem, MD Medical Director John R document in the editor.
2. Begin by entering the patient's name in the designated field. Ensure that both first and last names are clearly written.
3. Next, input the date of birth (DOB) in the format provided. This is crucial for identifying medical records accurately.
4. Fill in the daytime phone number. This allows for easy communication regarding the release of records.
5. Complete the address section with the patient's current address to ensure proper delivery of medical records.
6. In the authorization section, confirm that Helene A. Emsellem, MD is listed as the provider releasing records.
7. Specify where to send the medical records by filling out the recipient's information completely.
8. Indicate whether you are requesting full medical records or specify other details if necessary.
9. Sign and date at the bottom of the form to authorize this request. Make sure your signature matches your name above.

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