Fillable MEDICAL RECORDS RELEASE FORM - Lubbock Sports Medicine

MEDICAL RECORDS RELEASE FORM Patient Name: Account # This document authorizes the release of any and all patient information relative to my medical treatment from dates of service to . This should include all evaluation and physical therapy notes and information. Please expedite this information to: Name: Address: Fax Number: *Please note that we may take up to 15 days to fulfill your request for records. The...
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