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Records Release FROM Other Provider Form

Patient Name:

Patient Address:

City, State, Zip Code:

DOB:

Phone:

RE: Release of medical records for patient:

I authorize:

Practice Name:

To release a copy of all medical records related to my treatment rendered from the period:

From (Date):

Through (Date):

To Mertz MFM Center.

This information will be used to further assist in my medical care. It should be mailed, faxed, or emailed to:

Heather L. Mertz, MD
Mertz MFM Center
3815 Forrestgate Drive
Winston Salem, NC 27103
Phone: (336) 930-9600
Fax: (336) 930-9930
Email: frontdesk@mertzmfm.com

Date of Request:

Patient Signature:

Please sign electronically below.

Click submit and you hereby give consent to sign this document electronically.

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