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Office Use Only Account Number: Eff Mar 2018Authorization for Release of Medical Information Medical Records Release Form Sammy Lemma III, M.D. P.A. 1109 Church Street, Bastrop, TX 78602 Phone: (512)

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1. To fill out 1109 Church Street Bastrop, follow these steps:
2. Begin by entering your personal information, including your name, address, and contact information.
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4. Include any additional information related to the property, such as its size, condition, and any notable features.
5. If applicable, provide any supporting documents or attachments that may be required.
6. Double-check all the provided information to ensure accuracy and completeness.
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1109 Church Street, Bastrop is likely an address in Bastrop, Texas, which may refer to a specific property or building located at that location.

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