Medical Records Request
AUTHORIZATION TO RELEASE MEDICAL RECORDS TO PATIENT

Click Here to print a form to have your medical records sent to another clinic.
* Indicates Required Information
Patient Name: * Date Of Birth: *
Last 4 Digits Of SS#: * Phone: *

I authorize the Institute for Low Back and Neck Care to use or disclose the following healthcare information:
All my health care information maintained by the Institute for Low Back and Neck Care
My health care information for the following date(s):
Other:
Other (specify):

Please type the code shown in the image: *