Authorization of Release of Records Moss
Your Full Address:
Requesting From (Old Name of Doctor or Medical Office):
I authorize Desert River Solutions to SEND medical records TO THE FOLLOWING and by the FOLLOWING OPTION:
**Please choose ONLY ONE of the options**
Send To (Name):
Email Address On Where to Send To:
I DO I DO NOT
I authorize the release of an electronic version of my medical records in the possession or control of the above named provider/clinic/hospital; its employees and agents. I acknowledge that this authorization expires in one (1) year unless a different date is specified.
Please provide Relationship To Patient if You are NOT the Patient:
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization of Release of Records Moss
Agree & Sign