• Image
  • CONSENT FOR RELEASE OF INFORMATION

    Please complete the following form in its entirety to authorize MIND 24-7 to send and/or receive confidential medical information. Please note that medical records are processed Monday - Friday, 8:00 AM - 4:30 PM. Please allow up to 5 business days to process this request.

  •  / /
    Pick a Date
  • Signature

  • Clear
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Should be Empty: