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Release of Medical Information to Another Facility Form

Release of Medical Information to Another Facility Form
Address *
Address
Line 1
Line 2 (optional)
City
State/Province
Zip/Postal
There is some level of risk that information in email could be read by someone besides you. If requesting us to email your records to you, please indicate how you would like to receive your health information.
Authorize Records Released To: *
Authorize Records Released To:
Name
Address
City
State/Province
Zip/Postal
From Date
To Date
Records To Be Released: *
Release Records From: *
IF RECORDS ARE 40 OR MORE PAGES, THERE WILL BE A CHARGE OF $15.00 PLUS POSTAGE. PREPAYMENT IS REQUIRED.
This authorization will expire one year from signature date. I understand that I may revoke this authorization at any time by providing my written revocation. This release is executed in conformity with Wis. Stats. §§146.81-83, 51.30, 252.15 and 102.13.