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

Signature Certificate

Document name: Authorization for Release of Medical Records

Unique Document ID: 3f4a1cf9485bb1d3d27f268f0289e41fc195a61d

Build. Track. Sign Contracts.

Timestamp	Audit
March 3, 2021 2:04 pm MST	Authorization for Release of Medical Records 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