How to complete form

1.Fill in patient name, DOB, and address

2. Choose "Release to"

3. In the "Person/Organization" field, this is where you will list the provider information that you want your records sent to.  Plese make sure Fax is included. 

4. You will then check "Entire Patient Record" in the Information Requested section, which allows us to release your entire chart history/

5. The purpose of release should be marked "treatment" to continue your care. 

6.  Sign and date the form.

7. Witness is not needed at this time.