Medical Records Release 2023-11-14

Medical Records Release 1

Records to SFM
Date*

MonthDayYear
Date
To: Medical Records
Name of Physician/Practice to Release Records:*
Physician/Practice Fax Number*
Please enter a valid fax number.
Physician/Practice Phone Number*
Please enter a valid phone number.
RE: Patient Name*

First NameMiddle NameLast Name
From: Sparks Family Medicine, Ltd.

410 South Rampart, Suite 390

Las Vegas, NV 89145

Release of Records to:

Sparks Family Medicine, Ltd.

410 South Rampart, Suite 390

Las Vegas, NV 89145

Phone: 702-722-2200

Fax: 702-722-2201
Specific Authorization on Following Page(s)
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Medical Records Release 1