Records Request
1. Print this form and complete all fields
2. Sign and date it. **Physical signatures only; sorry, no electronic signatures accepted
3. Make sure to include a contact phone number as indicated at the bottom of the form
4. Email the completed form as an attachment to [email protected].
NOTE: The email address above is only for submitting completed records requests from patients. Thank you for understanding.
2. Sign and date it. **Physical signatures only; sorry, no electronic signatures accepted
3. Make sure to include a contact phone number as indicated at the bottom of the form
4. Email the completed form as an attachment to [email protected].
NOTE: The email address above is only for submitting completed records requests from patients. Thank you for understanding.
| records_request_2.pdf |
