PLEASE FORWARD MY MEDICAL RECORDS AS REQUESTED BELOW TO:
Burrows Family Practice, Inc. 1377 S. Grand Ave Glendora, CA 91740 Phone: 626-483-3348 Fax: 626-623-7258
NOTE: Hospital and medical office records may include information related to mental health, alcohol/drug, and HIV references. The actual treatment records from mental health and/or alcohol/drug departments, and/or results of HIV tests will not be disclosed unless specifically requested below.
SIGNATURES AND DATES REQUIRED IF ANY OF THE FOLLOWING BOXES ARE CHECKED
Duration: This authorization is effective immediately and shall remain in effect for one year from signature of date.
Revocation: This authorization may be revoked in writing at any time prior to the release of my information. Written revocation will not affect any action that has taken place before the receipt of the written revocation.
Disclosure: I understand that Burrows Family Practice may not lawfully further use or disclose this health information unless another authorization is obtained from me, or unless disclosure is specifically required or permitted by law.
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Burrows Family Practice, Inc.
1377 S. Grand Ave Glendora, CA 91740
Phone (626) 483-3348
Fax (626) 623-7258
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