Request for Medical Records (incoming)

Request for Medical Records to Dr. Jones

    From (Name of Doctor)*:
    Doctor's Address*:
    Doctor's City*:
    Doctor's State*:
    Doctor's Zipcode*:
    Doctor's Phone/Fax:
    Patient Name*:
    Date of Birth*:
    Address 1*:
    Address 2:
    City*:
    State*:
    Zipcode*:
    Your Email*:
    I HEREBY AUTHORIZE RELEASE OF REQUESTED INFORMATION
            TO REBECCA M. JONES, MD, AT 138 ELLIOT STREET, BRATTLEBORO, VT 05301
    Signature*:
    Date*:
    [recaptcha]

    This authorization is valid for 90 days and may be revoked at any time prior to.