Release Of Medical Records

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.

Today's Date

Patient's Name

Date Of Birth

Email Address

Address

Mailing Address (Home or New Physician's Office)

Physician's Fax or Email Address

Personal Fax

Delivery Options

Signature

Greenwich Medical Partners

644 West Putnam Ave, Suite 203

Greenwich, CT 06830

P.203-625-0333 F.203-625-8331