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EASTMAN WOZNIAK M. D. P. C. RAINBOW PEDIATRICS P. C. 2055 E. 14 Mile Road Birmingham MI 48009 248-645-1740 Fax 248-645-5304 RECORDS RELEASE FORM Name of Patient s Patient s Date of Birth Patient s Address Address City State Zip Please release the medical records from the office of Eastman Wozniak M. D. P. C. and send them to Name I authorize the release of medical records obtained in this office. Signature of Patient if 18 years or older or Patient or Guardian REASON FOR TRANSFERRING Moving...
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