Authorization to Release Copies of a Medical Record

For help with this form, call (800) 600-1478 or email roi@providerflow.com. 

Please verify all information, sign, date, and fax this form as your cover page with any Supporting documents to (614) 583-9082 or 

Mail to:
Provider Flow ROI, 1225 NW 17^th Avenue
Suite 103, Delray Beach, FL. 33445

ALL PATIENT REQUESTS MUST INCLUDE A COPY OF THEIR DRIVER’S LICENSE. 

This information is voluntary. I understand that Pinehurst Surgical Clinic will not base treatment, payment, enrollment, or eligibility for benefits on my signing this document. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving this revocation. 

Access electronic Medical Records Release Form here.

For help with this form, call (800) 600-1478 or email roi@providerflow.com