Green Earth Medicine Clinic
Release of Medical Information Form
If you already possess or can easily access your medical records in digital format (PDF) -- you DO NOT need to complete this form. Please email us your records directly to "email@example.com". You can also use this Patient Uploader form to attach and submit your records to us: https://form.jotform.com/201875671919063
Instructions For Completing this Release Form
Please complete this form with accurate information so we can request your records from the healthcare provider of your choice.
When possible please obtain the medical records fax number from your health provider -- you can obtain this by calling the health provider's office. If you are not able to obtain the fax number please provide the Name and Office Number of the health provider.
You must also list at least 1 medical problem in the Conditions List below -- please chose a condition that is a qualifying condition for an OMMP license. Reminder - conditions that qualify include anything documented for:
conditions of any type
- muscular, back pain, asthma/COPD
of any type
with anxiety or agitation
of any type and any history-- even if you are in remission
- poor appetite, weight loss
Degenerative neurologic disorders
of any type - ie. Parkinson's Disease, Strokes, Dementias, or Diabetic neuropathy or any type of neuropathy or chronic nervous system issues
Please make sure your info is EXACTLY CORRECT to avoid this request being rejected by the health provider