Patient Records Release Form

Please correct the errors described below.

hereby request a copy of my medical record as detailed below:

I understand that, in some cases, the charge for this record will be $0.25 per page for pages copied. I agree to pay this charge in full at the time I receive the copy of the records.

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

Your information will be encrypted.