Release of medical records.

I hereby request Greenwich Medical Partners to release my medical records held in their possession. I acknowledge that I will no longer be under the care of Greenwich Medical Partners. I hereby release Greenwich Medical Partners from any and all liability arising from the release of my medical records and for any and all uses and disclosures of my medical records and any related information.

Name Email Date of birth Address Receiving physician address Receiving physician fax or email Your personal fax number Delivery Please select Records mailed, faxed or emailed to the physician above Records emailed to me directly to the address provided above Records mailed or faxed to my home address Signature Today's date I authorize the release of these records.

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