The Orthopaedic Group

Patient Consent for Release of Health Information

Full Name

Date of Birth

Date

Address

City

State

Zip Code

Phone

Format: (000) 000-0000.

Email

example@example.com

INFORMATION REQUESTED FOR RELEASE

Dates of Service Requested: From Date to End Date
Office Visit Procedure/Operative Report Labs Physical Therapy Billing Records Injections Other:

Radiology Disk

We will notify The Orthopedic Group of your request for Imaging/Radiology disk. These will be provided by The Orthopedic Group directly.

There will be a processing fee for any records requests that are being released to a patient, insurance provider, or attorney. There is no charge for records being sent to a healthcare provider.

RECORD DELIVERY METHOD

Name/Facility

Attention

E mail

example@example.com

Fax Number

Mailing Address

City

State

Zip Code

Patient Name / Personal Representative

Signature

Date

Your medical records request will be processed by our partner company Acton Corporation. If you need assistance or have a question please call 205-408-6030.