Northwoods Surgery

Release of Information

Authorization Form
Release Records From: Northwoods Surgery Center, LLC

611 Veterans Parkway, Woodruff, WI 54568
Patient Name

First NameLast Name
Date Of Birth

DayMonthYear
Your Phone Number

Area CodePhone Number
Your Address

Street Address

CityState / Province

Postal / Zip CodeCountry
Your E-mail Address
Reason for Release
Records Requested

Other
Include any Special Requests Here:
Where Should Records be Sent?
Healthcare Provider

Name

Street Address

CityState

Zip Code
Healthcare Provider Fax Number

Area CodeFax Number
Signature
My Products
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Copy of Medical Records$15.00
Signature Date

MonthDayYear
Should be Empty:

Release of Information