Patient Medical Record Request

I hereby release the above-mentioned institution from any liability which may arise from the release and/or examination of the information indicated above. This information is CONFIDENTIAL. Re-disclosure of this information is strictly prohibited by law without the prior written permission of the individual to whom it pertains.

IMPORTANT: This electronic transmission contains confidential information, some or all of which may be protected health information as defined by the federal Health Insurance Portability & Accountability Act (HIPAA) Privacy Rule. This transmission is intended for the exclusive use of the individual or entity to whom it is addressed and may contain information that is proprietary, privileged, confidential and/or exempt from disclosure under applicable law. If you are not the intended recipient (or an employee or agent responsible for delivering this electronic transmission to the intended recipient), you are hereby notified that any disclosure, dissemination, distribution or copying of this information is strictly prohibited and may be subject to legal restriction or sanction. Please notify the sender by telephone (number listed above) to arrange the return or destruction of the information and all copies.