Authorization to Release Copies of a Medical Record
For help with this form, call (800) 600-1478 or email firstname.lastname@example.org.
Please verify all information, sign, date, and fax this form as your cover page with any Supporting documents to (614) 583-9082 or
Provider Flow ROI, 1225 NW 17th 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.
For help with this form, call (800) 600-1478 or email email@example.com