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):

Address:

Email Address On Where to Send To:

I DO I DO NOT

I DO I DO NOT

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

Please Confirm full name and signature.

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• Type In Signature
  

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

Insert Signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signature Certificate

Document name: Authorization of Release of Records Moss

Unique Document ID: 826b9087b47f506f88d032c20da4677460b03ecf

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Timestamp	Audit
December 31, 2021 8:30 am MST	Authorization of Release of Records Moss Uploaded by Andrew Szmuc - [email protected] IP 70.166.116.246

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://desertriversolutions.com/

Audit Trail Serial# f6004802ea751b8a4010eb13ad2b9de2