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Medical Record Request

Medical records are kept in strict confidence and are not released without the written authorization of the patient except as permitted or required by law.

If you are requested a copy of your medical record, please complete the form below. Proof of your identification is required. If this form is being completed by patient or guardian, a copy of your photo ID required.

Click here to view a PDF version of this form.

Name
MM slash DD slash YYYY
Release to:
Max. file size: 49 MB.