RECORDS RELEASE

Woodbridge Office: 2280 Opitz Blvd · Suite 230 · Woodbridge, VA 22191 · (703) 583-5959 | Chantilly Office: 3914 Centreville Rd · Suite 200 · Chantilly, VA 20151 · (703) 490-5599 | Fax: (703) 583-5995

Please correct the errors described below.

These records can be released to above person (check one):

The following items and/or dates of service should be released:

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I have been informed of Potomac Podiatry Group’s records release protocol. I understand Potomac Podiatry Group, PLLC will not be responsible for any security breach of my personal information.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

This Records Release expires 90 days after signed. Please allow up to 30 days to receive records.

Electronic Format Fees: $15.00 Administration fee, plus $0.37 per page for first 50 pages and $0.18 per page thereafter

Paper Copy Fees: $15.00 Administration fee, plus $0.50 per page for first 50 pages and $0.25 per page thereafter

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