• Release of Information

    Release of Information

  • PATIENT INFORMATION:

  •  - -
    Pick a Date
  • REQUESTS RECORDS FROM (WHO HAS YOUR RECORDS NOW):

  • I hereby authorize:

  • TO RELEASE INFORMATION TO (WHO YOU WANT TO RECEIVE YOUR RECORDS):

  • INFORMATION TO BE RELEASED:

  •  - -
    Pick a Date
  •  - -
    Pick a Date
  •  - -
    Pick a Date
  • Clear
  • If I am unable to personally pick up my records from Peak Gastroenterology Associates PC, I authorize:

  • Should be Empty: