For CMI Office Use:
___ Released records as requested.
Request denied due to one of the following- please check all that apply.
___ Information was compile for civil, crimincal or administrative actions.
___ Was not created or performed by this practice.
___ Professional decision that this information may be harmful to the patient.
Authorizing signature:_______________________________ Date:___________
Records copied and sent (date/initials) __________ /_____
Request denial, patient notified by:_____________________ Date:__________