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Begin by filling out the 'Release From' section. Enter the practice name, address, city, state, telephone number, and zip code in the designated fields.
In the 'Please release records for the following patient(s)' section, select the appropriate office location by checking the corresponding box.
List each patient's name and date of birth in the provided fields. Ensure accuracy to avoid any delays in processing.
Have the parent, guardian, or patient sign in the designated area and enter the date of signing below.
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We are a multispecialty physician group with more than 1,000 doctors, nurse practitioners and physician assistants at over 300 locations throughout northern and
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