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RECORDS RELEASE To whom it may concern: ___ Please release my records to:River, Gupta & Grosz Cardiology, P.C. 600 Providence Park Dr. E. Mobile, AL 36695Patient Name: ___DOB:___SS#:___ By signing
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Obtain a copy of the please release my records form from the appropriate source or website.
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Fill out the personal information section, including your name, address, date of birth, and contact information.
03
Specify where you would like the records to be released to, providing the name and address of the recipient.
04
Include the specific records you are requesting to be released, including dates and types of documents.
05
Sign and date the form, certifying that the information provided is accurate and complete.
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Submit the completed form to the designated recipient, whether that be a healthcare provider, insurance company, or other entity.

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Please release my records is a request for the disclosure of an individual's documents or information.
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